- 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
- $1,254.88 / $1,262.28 / $3,110.37
| Professional | | $1,254.88 | $1,262.28 | $3,110.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,151.00 / $2,151.00 / $2,151.00
| Facility | | $2,151.00 | $2,151.00 | $2,151.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.94 / $1,370.67 / $2,135.55
| Professional | | $1,014.94 | $1,370.67 | $2,135.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,311.00 / $5,170.00 / $5,170.00
| Facility | | $4,311.00 | $5,170.00 | $5,170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.69 / $1,291.51 / $2,899.07
| Professional | | $1,019.69 | $1,291.51 | $2,899.07 |