- 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
- $460.65 / $528.47 / $528.47
| Professional | | $460.65 | $528.47 | $528.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.32 / $587.47 / $1,021.09
| Professional | | $461.32 | $587.47 | $1,021.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,783.00 / $2,783.00 / $2,783.00
| Facility | | $2,783.00 | $2,783.00 | $2,783.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.30 / $686.88 / $1,248.30
| Professional | | $482.30 | $686.88 | $1,248.30 |