- 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
- $535.26 / $551.08 / $628.77
| Professional | | $535.26 | $551.08 | $628.77 |
- 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
- $552.51 / $657.43 / $1,142.83
| Professional | | $552.51 | $657.43 | $1,142.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,783.00 / $2,783.00 / $2,783.00
| Facility | | $2,783.00 | $2,783.00 | $2,783.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $490.61 / $635.23 / $1,450.75
| Professional | | $490.61 | $635.23 | $1,450.75 |