- 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
- $1,115.52 / $1,270.45 / $1,270.45
| Professional | | $1,115.52 | $1,270.45 | $1,270.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.98 / $1,316.69 / $2,328.02
| Professional | | $1,118.98 | $1,316.69 | $2,328.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,678.47 / $1,678.47 / $1,678.47
| Professional | | $1,678.47 | $1,678.47 | $1,678.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,200.00
| Facility | | $2,200.00 | $2,200.00 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.09 / $1,406.11 / $2,962.01
| Professional | | $1,077.09 | $1,406.11 | $2,962.01 |