- 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
- $2,407.36 / $2,734.78 / $2,734.78
| Professional | | $2,407.36 | $2,734.78 | $2,734.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,376.69 / $2,814.48 / $4,738.88
| Professional | | $2,376.69 | $2,814.48 | $4,738.88 |
- 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
- $2,223.48 / $2,767.07 / $6,297.23
| Professional | | $2,223.48 | $2,767.07 | $6,297.23 |