- 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
- $3,356.95 / $3,822.76 / $3,822.76
| Professional | | $3,356.95 | $3,822.76 | $3,822.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,324.03 / $3,892.08 / $6,825.79
| Professional | | $3,324.03 | $3,892.08 | $6,825.79 |
- 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
- $3,048.15 / $3,622.89 / $8,724.45
| Professional | | $3,048.15 | $3,622.89 | $8,724.45 |