- 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
- $808.46 / $924.80 / $924.80
| Professional | | $808.46 | $924.80 | $924.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.89 / $957.25 / $1,672.75
| Professional | | $816.89 | $957.25 | $1,672.75 |
- 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
- $767.12 / $933.62 / $2,102.92
| Professional | | $767.12 | $933.62 | $2,102.92 |