- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,736.00 / $4,736.00 / $6,907.00
| Facility | | $4,736.00 | $4,736.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $829.63 / $1,075.31 / $1,170.64
| Professional | | $829.63 | $1,075.31 | $1,170.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $640.00 / $640.00 / $640.00
| Facility | | $640.00 | $640.00 | $640.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $722.74 / $755.45 / $1,202.40
| Professional | | $722.74 | $755.45 | $1,202.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.51 / $853.54 / $2,028.63
| Professional | | $679.51 | $853.54 | $2,028.63 |