- 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
- $758.77 / $884.28 / $884.28
| Professional | | $758.77 | $884.28 | $884.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.80 / $889.04 / $1,502.04
| Professional | | $756.80 | $889.04 | $1,502.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,200.00
| Facility | | $2,200.00 | $2,200.00 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.77 / $835.57 / $1,902.47
| Professional | | $682.77 | $835.57 | $1,902.47 |