- 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
- $812.00 / $909.49 / $942.37
| Professional | | $812.00 | $909.49 | $942.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,904.41 / $4,904.41 / $4,904.41
| Facility | | $4,904.41 | $4,904.41 | $4,904.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.37 / $940.08 / $1,682.66
| Professional | | $800.37 | $940.08 | $1,682.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,200.00
| Facility | | $2,200.00 | $2,200.00 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.16 / $1,004.77 / $2,041.24
| Professional | | $743.16 | $1,004.77 | $2,041.24 |