- 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
- $1,783.80 / $2,015.80 / $2,015.80
| Professional | | $1,783.80 | $2,015.80 | $2,015.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.29 / $1,846.22 / $3,456.46
| Professional | | $1,652.29 | $1,846.22 | $3,456.46 |
- 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
- $1,671.75 / $2,023.85 / $4,737.55
| Professional | | $1,671.75 | $2,023.85 | $4,737.55 |