- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,583.00 / $6,583.00 / $9,090.79
| Facility | | $6,583.00 | $6,583.00 | $9,090.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,134.76 / $6,217.27 / $6,583.00
| Professional | | $3,134.76 | $6,217.27 | $6,583.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,395.99 / $3,939.35 / $9,372.93
| Facility | | $3,395.99 | $3,939.35 | $9,372.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,702.14 / $4,702.14 / $5,224.60
| Facility | | $4,702.14 | $4,702.14 | $5,224.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.33 / $3,134.76 / $5,224.60
| Professional | | $2,194.33 | $3,134.76 | $5,224.60 |