- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,816.00 / $5,816.00 / $6,907.00
| Facility | | $5,816.00 | $5,816.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.98 / $705.46 / $705.46
| Professional | | $624.98 | $705.46 | $705.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $559.16 / $755.22 / $1,318.54
| Professional | | $559.16 | $755.22 | $1,318.54 |
- 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
- $583.82 / $740.26 / $1,578.49
| Professional | | $583.82 | $740.26 | $1,578.49 |