- 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
- $2,903.32 / $3,309.34 / $3,309.34
| Professional | | $2,903.32 | $3,309.34 | $3,309.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,874.63 / $3,366.52 / $5,982.20
| Professional | | $2,874.63 | $3,366.52 | $5,982.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.00 / $2,530.00 / $2,530.00
| Facility | | $2,530.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,748.01 / $3,664.80 / $7,659.50
| Professional | | $2,748.01 | $3,664.80 | $7,659.50 |