- 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
- $1,693.73 / $1,693.73 / $2,031.35
| Professional | | $1,693.73 | $1,693.73 | $2,031.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $789.28 / $4,396.54 / $5,595.59
| Professional | | $789.28 | $4,396.54 | $5,595.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,028.00 / $3,028.00 / $3,028.00
| Facility | | $3,028.00 | $3,028.00 | $3,028.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $680.04 / $2,964.84 / $6,815.04
| Professional | | $680.04 | $2,964.84 | $6,815.04 |