- 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
- $709.22 / $812.02 / $812.02
| Professional | | $709.22 | $812.02 | $812.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.57 / $860.72 / $1,449.91
| Professional | | $734.57 | $860.72 | $1,449.91 |
- 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
- $684.84 / $899.28 / $1,877.29
| Professional | | $684.84 | $899.28 | $1,877.29 |