- 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
- $784.54 / $897.63 / $897.63
| Professional | | $784.54 | $897.63 | $897.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.39 / $929.74 / $1,612.12
| Professional | | $793.39 | $929.74 | $1,612.12 |
- 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
- $754.70 / $957.26 / $2,040.51
| Professional | | $754.70 | $957.26 | $2,040.51 |