- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,178.28 / $2,407.65 / $6,907.00
| Facility | | $2,178.28 | $2,407.65 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.51 / $913.04 / $1,067.64
| Professional | | $741.51 | $913.04 | $1,067.64 |
- 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
- $627.60 / $736.02 / $1,207.96
| Professional | | $627.60 | $736.02 | $1,207.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.52 / $835.53 / $1,989.42
| Professional | | $689.52 | $835.53 | $1,989.42 |