- 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
- $1,723.28 / $1,943.67 / $1,943.67
| Professional | | $1,723.28 | $1,943.67 | $1,943.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,695.20 / $2,173.81 / $3,646.79
| Professional | | $1,695.20 | $2,173.81 | $3,646.79 |
- 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
- $1,638.64 / $2,343.54 / $4,430.47
| Professional | | $1,638.64 | $2,343.54 | $4,430.47 |