- 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
- $2,312.19 / $2,626.33 / $2,626.33
| Professional | | $2,312.19 | $2,626.33 | $2,626.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,308.33 / $2,765.21 / $4,883.43
| Professional | | $2,308.33 | $2,765.21 | $4,883.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,783.00 / $2,783.00 / $2,783.00
| Facility | | $2,783.00 | $2,783.00 | $2,783.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.30 / $2,937.76 / $6,051.79
| Professional | | $2,238.30 | $2,937.76 | $6,051.79 |