- 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
- $2,175.65 / $2,453.52 / $2,453.52
| Professional | | $2,175.65 | $2,453.52 | $2,453.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,131.80 / $2,600.23 / $4,539.42
| Professional | | $2,131.80 | $2,600.23 | $4,539.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.00 / $2,530.00 / $2,530.00
| Facility | | $2,530.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,075.55 / $2,836.27 / $5,611.77
| Professional | | $2,075.55 | $2,836.27 | $5,611.77 |