- 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
- $1,042.75 / $1,042.75 / $1,224.23
| Professional | | $1,042.75 | $1,042.75 | $1,224.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,882.14 / $4,882.14 / $4,882.14
| Facility | | $4,882.14 | $4,882.14 | $4,882.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.83 / $1,249.26 / $2,213.07
| Professional | | $1,080.83 | $1,249.26 | $2,213.07 |
- 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
- $1,020.33 / $1,336.79 / $2,796.43
| Professional | | $1,020.33 | $1,336.79 | $2,796.43 |