- 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
- $851.63 / $973.48 / $973.48
| Professional | | $851.63 | $973.48 | $973.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,181.26 / $5,181.26 / $5,181.26
| Facility | | $5,181.26 | $5,181.26 | $5,181.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $858.70 / $1,005.93 / $1,759.33
| Professional | | $858.70 | $1,005.93 | $1,759.33 |
- 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
- $820.46 / $1,017.81 / $2,218.33
| Professional | | $820.46 | $1,017.81 | $2,218.33 |