- 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
- $1,137.15 / $1,304.44 / $1,304.44
| Professional | | $1,137.15 | $1,304.44 | $1,304.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,253.94 / $10,253.94 / $10,253.94
| Facility | | $10,253.94 | $10,253.94 | $10,253.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.60 / $1,339.08 / $2,305.63
| Professional | | $1,142.60 | $1,339.08 | $2,305.63 |
- 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
- $1,061.70 / $1,348.25 / $2,936.94
| Professional | | $1,061.70 | $1,348.25 | $2,936.94 |