- 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
- $965.62 / $1,101.96 / $1,101.96
| Professional | | $965.62 | $1,101.96 | $1,101.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.85 / $1,143.83 / $1,993.57
| Professional | | $973.85 | $1,143.83 | $1,993.57 |
- 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
- $931.59 / $1,048.32 / $2,518.79
| Professional | | $931.59 | $1,048.32 | $2,518.79 |