- 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
- $1,038.22 / $1,202.80 / $1,202.80
| Professional | | $1,038.22 | $1,202.80 | $1,202.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,732.57 / $1,732.57 / $1,732.57
| Facility | | $1,732.57 | $1,732.57 | $1,732.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.08 / $1,212.98 / $2,147.67
| Professional | | $1,034.08 | $1,212.98 | $2,147.67 |
- 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
- $974.74 / $1,368.92 / $2,635.46
| Professional | | $974.74 | $1,368.92 | $2,635.46 |