- 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
- $2,290.23 / $2,580.96 / $2,580.96
| Professional | | $2,290.23 | $2,580.96 | $2,580.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,252.80 / $2,684.96 / $4,725.03
| Professional | | $2,252.80 | $2,684.96 | $4,725.03 |
- 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
- $2,182.56 / $3,299.00 / $5,895.32
| Professional | | $2,182.56 | $3,299.00 | $5,895.32 |