- 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
- $748.78 / $907.58 / $977.38
| Professional | | $748.78 | $907.58 | $977.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $790.00 / $790.00 / $790.00
| Facility | | $790.00 | $790.00 | $790.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.16 / $676.48 / $1,086.96
| Professional | | $631.16 | $676.48 | $1,086.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.35 / $734.97 / $1,758.69
| Professional | | $606.35 | $734.97 | $1,758.69 |