- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,911.25 / $6,911.25 / $7,176.30
| Professional | | $6,911.25 | $6,911.25 | $7,176.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.00 / $820.00 / $1,025.00
| Professional | | $683.00 | $820.00 | $1,025.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.77 / $584.91 / $830.67
| Professional | | $482.77 | $584.91 | $830.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.30 / $712.56 / $1,445.39
| Professional | | $586.30 | $712.56 | $1,445.39 |