- 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
- $2,494.36 / $2,831.15 / $2,831.15
| Professional | | $2,494.36 | $2,831.15 | $2,831.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,491.06 / $3,058.79 / $5,198.60
| Professional | | $2,491.06 | $3,058.79 | $5,198.60 |
- 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
- $2,418.15 / $3,109.21 / $6,538.08
| Professional | | $2,418.15 | $3,109.21 | $6,538.08 |