- 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
- $769.83 / $877.38 / $877.38
| Professional | | $769.83 | $877.38 | $877.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $773.25 / $919.07 / $1,606.06
| Professional | | $773.25 | $919.07 | $1,606.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.00 / $2,530.00 / $2,530.00
| Facility | | $2,530.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.46 / $1,148.48 / $2,008.00
| Professional | | $765.46 | $1,148.48 | $2,008.00 |