- 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
- $1,232.85 / $1,404.38 / $1,404.38
| Professional | | $1,232.85 | $1,404.38 | $1,404.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.08 / $1,318.92 / $2,362.31
| Professional | | $1,217.08 | $1,318.92 | $2,362.31 |
- 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
- $1,135.98 / $1,342.38 / $3,226.24
| Professional | | $1,135.98 | $1,342.38 | $3,226.24 |