- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,679.25 / $2,679.25 / $6,907.00
| Facility | | $2,679.25 | $2,679.25 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.69 / $1,042.51 / $1,042.51
| Professional | | $891.69 | $1,042.51 | $1,042.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.08 / $944.18 / $1,711.60
| Professional | | $880.08 | $944.18 | $1,711.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,485.00 / $1,485.00 / $1,485.00
| Facility | | $1,485.00 | $1,485.00 | $1,485.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.83 / $911.59 / $2,170.66
| Professional | | $802.83 | $911.59 | $2,170.66 |