- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,294.55 / $5,294.55 / $6,907.00
| Facility | | $5,294.55 | $5,294.55 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,038.33 / $1,184.32 / $2,998.25
| Professional | | $1,038.33 | $1,184.32 | $2,998.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.65 / $1,223.48 / $2,162.96
| Professional | | $1,044.65 | $1,223.48 | $2,162.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,811.20 / $9,811.20 / $9,811.20
| Professional | | $9,811.20 | $9,811.20 | $9,811.20 |
- 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
- $1,001.74 / $1,286.13 / $2,708.47
| Professional | | $1,001.74 | $1,286.13 | $2,708.47 |