- 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
- $2,884.12 / $3,287.10 / $3,287.10
| Professional | | $2,884.12 | $3,287.10 | $3,287.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,652.19 / $3,367.83 / $5,930.34
| Professional | | $2,652.19 | $3,367.83 | $5,930.34 |
- 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
- $2,387.61 / $2,997.19 / $7,481.62
| Professional | | $2,387.61 | $2,997.19 | $7,481.62 |