- 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
- $606.53 / $691.56 / $691.56
| Professional | | $606.53 | $691.56 | $691.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $610.74 / $719.22 / $1,249.75
| Professional | | $610.74 | $719.22 | $1,249.75 |
- 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
- $540.77 / $721.81 / $1,481.81
| Professional | | $540.77 | $721.81 | $1,481.81 |