- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,816.00 / $5,816.00 / $6,907.00
| Facility | | $5,816.00 | $5,816.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.12 / $528.98 / $2,733.71
| Professional | | $363.12 | $528.98 | $2,733.71 |
- 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
- $346.83 / $1,776.20 / $2,456.44
| Professional | | $346.83 | $1,776.20 | $2,456.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,951.10 / $2,367.94 / $5,369.58
| Professional | | $1,951.10 | $2,367.94 | $5,369.58 |