- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,316.00 / $6,907.00 / $8,005.65
| Facility | | $6,316.00 | $6,907.00 | $8,005.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.28 / $1,047.03 / $1,047.03
| Professional | | $914.28 | $1,047.03 | $1,047.03 |
- 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
- $881.96 / $975.43 / $1,798.16
| Professional | | $881.96 | $975.43 | $1,798.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,320.00 / $1,320.00 / $1,320.00
| Facility | | $1,320.00 | $1,320.00 | $1,320.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.38 / $1,032.73 / $2,378.50
| Professional | | $817.38 | $1,032.73 | $2,378.50 |