- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,736.00 / $6,907.00 / $8,977.50
| Facility | | $4,736.00 | $6,907.00 | $8,977.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.92 / $844.92 / $967.71
| Professional | | $844.92 | $844.92 | $967.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.92 / $1,196.97 / $1,662.96
| Professional | | $859.92 | $1,196.97 | $1,662.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,840.78 / $6,840.78 / $6,840.78
| Facility | | $6,840.78 | $6,840.78 | $6,840.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.59 / $1,159.33 / $2,158.57
| Professional | | $946.59 | $1,159.33 | $2,158.57 |