- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,924.00 / $5,484.00 / $6,718.00
| Facility | | $1,924.00 | $5,484.00 | $6,718.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,433.00 / $2,433.00 / $2,931.51
| Professional | | $2,433.00 | $2,433.00 | $2,931.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.75 / $2,634.91 / $3,353.52
| Professional | | $218.75 | $2,634.91 | $3,353.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.00 / $1,981.00 / $1,981.00
| Facility | | $1,981.00 | $1,981.00 | $1,981.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,001.38 / $4,128.41 / $4,401.33
| Professional | | $3,001.38 | $4,128.41 | $4,401.33 |