- 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
- $910.30 / $1,039.82 / $1,039.82
| Professional | | $910.30 | $1,039.82 | $1,039.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $918.15 / $1,078.03 / $1,891.00
| Professional | | $918.15 | $1,078.03 | $1,891.00 |
- 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
- $855.27 / $1,132.16 / $2,371.73
| Professional | | $855.27 | $1,132.16 | $2,371.73 |