- 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
- $1,089.32 / $1,364.02 / $1,467.39
| Professional | | $1,089.32 | $1,364.02 | $1,467.39 |
- 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
- $933.93 / $960.59 / $1,588.08
| Professional | | $933.93 | $960.59 | $1,588.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.41 / $1,043.00 / $2,640.46
| Professional | | $874.41 | $1,043.00 | $2,640.46 |