- 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
- $1,910.90 / $2,154.77 / $2,154.77
| Professional | | $1,910.90 | $2,154.77 | $2,154.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,880.10 / $2,306.19 / $3,974.60
| Professional | | $1,880.10 | $2,306.19 | $3,974.60 |
- 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
- $1,818.56 / $2,625.46 / $4,916.93
| Professional | | $1,818.56 | $2,625.46 | $4,916.93 |