- 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
- $944.82 / $1,085.58 / $1,085.58
| Professional | | $944.82 | $1,085.58 | $1,085.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.71 / $1,133.23 / $1,938.39
| Professional | | $968.71 | $1,133.23 | $1,938.39 |
- 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
- $792.61 / $1,187.30 / $2,490.96
| Professional | | $792.61 | $1,187.30 | $2,490.96 |