- 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
- $1,274.49 / $1,423.13 / $1,424.31
| Professional | | $1,274.49 | $1,423.13 | $1,424.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,200.76 / $3,200.76 / $3,200.76
| Facility | | $3,200.76 | $3,200.76 | $3,200.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.45 / $1,490.16 / $2,648.95
| Professional | | $1,243.45 | $1,490.16 | $2,648.95 |
- 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
- $1,206.33 / $1,487.20 / $3,317.42
| Professional | | $1,206.33 | $1,487.20 | $3,317.42 |