- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,316.00 / $6,316.00 / $6,907.00
| Facility | | $6,316.00 | $6,316.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.75 / $736.15 / $736.15
| Professional | | $652.75 | $736.15 | $736.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.24 / $753.45 / $1,280.60
| Professional | | $644.24 | $753.45 | $1,280.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.00 / $2,530.00 / $2,530.00
| Facility | | $2,530.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $618.86 / $805.76 / $1,709.01
| Professional | | $618.86 | $805.76 | $1,709.01 |