- 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
- $1,433.86 / $1,583.88 / $1,583.88
| Professional | | $1,433.86 | $1,583.88 | $1,583.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.63 / $1,680.11 / $2,939.79
| Professional | | $1,375.63 | $1,680.11 | $2,939.79 |
- 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
- $1,362.89 / $1,814.17 / $3,684.91
| Professional | | $1,362.89 | $1,814.17 | $3,684.91 |