- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $8,431.00 / $10,303.00
| Facility | | $2,747.00 | $8,431.00 | $10,303.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.65 / $855.65 / $855.65
| Professional | | $855.65 | $855.65 | $855.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.34 / $1,196.02 / $1,395.35
| Professional | | $1,096.34 | $1,196.02 | $1,395.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,425.00 / $7,425.00 / $7,425.00
| Facility | | $7,425.00 | $7,425.00 | $7,425.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.99 / $1,442.43 / $1,583.90
| Professional | | $1,094.99 | $1,442.43 | $1,583.90 |