- 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
- $892.05 / $1,017.54 / $1,017.54
| Professional | | $892.05 | $1,017.54 | $1,017.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.46 / $1,068.49 / $1,886.73
| Professional | | $891.46 | $1,068.49 | $1,886.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,783.00 / $2,783.00 / $2,783.00
| Facility | | $2,783.00 | $2,783.00 | $2,783.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.18 / $1,120.35 / $2,352.76
| Professional | | $870.18 | $1,120.35 | $2,352.76 |