- 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
- $681.44 / $767.81 / $767.81
| Professional | | $681.44 | $767.81 | $767.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.94 / $787.11 / $1,369.38
| Professional | | $672.94 | $787.11 | $1,369.38 |
- 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
- $645.27 / $832.15 / $1,784.11
| Professional | | $645.27 | $832.15 | $1,784.11 |