- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,316.00 / $6,316.00 / $6,907.00
| Facility | | $6,316.00 | $6,316.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,464.59 / $2,791.54 / $2,791.54
| Professional | | $2,464.59 | $2,791.54 | $2,791.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,192.73 / $2,951.77 / $5,086.60
| Professional | | $2,192.73 | $2,951.77 | $5,086.60 |
- 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
- $2,199.26 / $2,838.19 / $6,468.02
| Professional | | $2,199.26 | $2,838.19 | $6,468.02 |