- 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
- $981.46 / $1,119.43 / $1,119.43
| Professional | | $981.46 | $1,119.43 | $1,119.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $989.23 / $1,158.71 / $2,024.27
| Professional | | $989.23 | $1,158.71 | $2,024.27 |
- 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
- $925.34 / $1,104.50 / $2,561.48
| Professional | | $925.34 | $1,104.50 | $2,561.48 |