- 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
- $567.60 / $626.67 / $626.67
| Professional | | $567.60 | $626.67 | $626.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.35 / $700.93 / $1,218.00
| Professional | | $556.35 | $700.93 | $1,218.00 |
- 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
- $540.15 / $727.56 / $1,460.44
| Professional | | $540.15 | $727.56 | $1,460.44 |