- 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
- $697.89 / $865.75 / $933.71
| Professional | | $697.89 | $865.75 | $933.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,221.00 / $1,221.00 / $1,221.00
| Facility | | $1,221.00 | $1,221.00 | $1,221.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.07 / $649.61 / $1,021.76
| Professional | | $583.07 | $649.61 | $1,021.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $554.16 / $650.22 / $1,564.54
| Professional | | $554.16 | $650.22 | $1,564.54 |