- 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
- $1,523.65 / $1,729.89 / $1,729.89
| Professional | | $1,523.65 | $1,729.89 | $1,729.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.21 / $1,796.42 / $3,131.46
| Professional | | $1,518.21 | $1,796.42 | $3,131.46 |
- 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
- $1,381.67 / $1,802.70 / $3,995.65
| Professional | | $1,381.67 | $1,802.70 | $3,995.65 |