- 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
- $1,455.77 / $1,642.40 / $1,642.40
| Professional | | $1,455.77 | $1,642.40 | $1,642.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,056.85 / $4,056.85 / $4,056.85
| Facility | | $4,056.85 | $4,056.85 | $4,056.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,430.17 / $1,744.13 / $3,094.90
| Professional | | $1,430.17 | $1,744.13 | $3,094.90 |
- 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
- $1,383.27 / $1,857.87 / $3,740.02
| Professional | | $1,383.27 | $1,857.87 | $3,740.02 |