- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,060.00 / $2,060.00 / $6,907.00
| Facility | | $2,060.00 | $2,060.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.27 / $717.27 / $841.29
| Professional | | $717.27 | $717.27 | $841.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $698.30 / $849.21 / $1,452.54
| Professional | | $698.30 | $849.21 | $1,452.54 |
- 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
- $645.09 / $882.84 / $1,744.16
| Professional | | $645.09 | $882.84 | $1,744.16 |