- 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
- $1,100.65 / $1,259.14 / $1,259.14
| Professional | | $1,100.65 | $1,259.14 | $1,259.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,326.15 / $10,326.15 / $10,326.15
| Facility | | $10,326.15 | $10,326.15 | $10,326.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.74 / $1,292.47 / $2,279.59
| Professional | | $1,115.74 | $1,292.47 | $2,279.59 |
- 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
- $1,060.30 / $1,278.02 / $2,866.78
| Professional | | $1,060.30 | $1,278.02 | $2,866.78 |