- 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
- $1,860.38 / $2,108.62 / $2,108.62
| Professional | | $1,860.38 | $2,108.62 | $2,108.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,848.53 / $2,157.83 / $3,637.28
| Professional | | $1,848.53 | $2,157.83 | $3,637.28 |
- 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
- $1,766.73 / $2,282.87 / $4,879.51
| Professional | | $1,766.73 | $2,282.87 | $4,879.51 |