- 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
- $2,483.87 / $2,798.46 / $2,798.46
| Professional | | $2,483.87 | $2,798.46 | $2,798.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,442.67 / $3,303.56 / $5,158.28
| Professional | | $2,442.67 | $3,303.56 | $5,158.28 |
- 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
- $2,336.30 / $2,953.98 / $6,395.17
| Professional | | $2,336.30 | $2,953.98 | $6,395.17 |