- 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
- $764.45 / $768.97 / $1,043.39
| Professional | | $764.45 | $768.97 | $1,043.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,025.00 / $3,025.00 / $3,025.00
| Facility | | $3,025.00 | $3,025.00 | $3,025.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $686.57 / $845.64 / $1,320.61
| Professional | | $686.57 | $845.64 | $1,320.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,924.00 / $2,783.00 / $2,783.00
| Facility | | $1,924.00 | $2,783.00 | $2,783.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.59 / $799.50 / $1,752.21
| Professional | | $647.59 | $799.50 | $1,752.21 |