- 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
- $1,027.17 / $1,164.09 / $1,164.09
| Professional | | $1,027.17 | $1,164.09 | $1,164.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.85 / $1,221.63 / $2,159.83
| Professional | | $1,030.85 | $1,221.63 | $2,159.83 |
- 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
- $979.02 / $1,252.23 / $2,687.38
| Professional | | $979.02 | $1,252.23 | $2,687.38 |