- 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
- $977.60 / $1,116.11 / $1,116.11
| Professional | | $977.60 | $1,116.11 | $1,116.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.15 / $1,158.75 / $2,037.37
| Professional | | $985.15 | $1,158.75 | $2,037.37 |
- 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
- $942.11 / $1,188.49 / $2,547.23
| Professional | | $942.11 | $1,188.49 | $2,547.23 |