- 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
- $917.74 / $1,044.97 / $1,044.97
| Professional | | $917.74 | $1,044.97 | $1,044.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.60 / $1,090.70 / $1,927.57
| Professional | | $919.60 | $1,090.70 | $1,927.57 |
- 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
- $886.18 / $1,322.88 / $2,396.02
| Professional | | $886.18 | $1,322.88 | $2,396.02 |