- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,736.00 / $6,907.00 / $6,965.62
| Facility | | $4,736.00 | $6,907.00 | $6,965.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.38 / $1,005.64 / $1,005.64
| Professional | | $865.38 | $1,005.64 | $1,005.64 |
- 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
- $860.42 / $1,011.73 / $1,697.11
| Professional | | $860.42 | $1,011.73 | $1,697.11 |
- 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
- $786.27 / $1,035.00 / $2,183.12
| Professional | | $786.27 | $1,035.00 | $2,183.12 |