- 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
- $1,023.40 / $1,167.08 / $1,167.08
| Professional | | $1,023.40 | $1,167.08 | $1,167.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,882.14 / $4,882.14 / $4,882.14
| Facility | | $4,882.14 | $4,882.14 | $4,882.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.78 / $1,237.53 / $2,139.09
| Professional | | $1,031.78 | $1,237.53 | $2,139.09 |
- 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
- $986.52 / $1,331.65 / $2,667.30
| Professional | | $986.52 | $1,331.65 | $2,667.30 |