- 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
- $1,265.04 / $1,408.39 / $1,408.39
| Professional | | $1,265.04 | $1,408.39 | $1,408.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.33 / $1,466.64 / $2,609.79
| Professional | | $1,231.33 | $1,466.64 | $2,609.79 |
- 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
- $1,193.50 / $1,426.62 / $3,248.18
| Professional | | $1,193.50 | $1,426.62 | $3,248.18 |