- 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
- $630.49 / $722.16 / $722.16
| Professional | | $630.49 | $722.16 | $722.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.09 / $749.41 / $1,291.09
| Professional | | $626.09 | $749.41 | $1,291.09 |
- 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
- $573.74 / $731.82 / $1,640.25
| Professional | | $573.74 | $731.82 | $1,640.25 |