- 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
- $1,192.98 / $1,499.37 / $1,538.18
| Professional | | $1,192.98 | $1,499.37 | $1,538.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $790.00 / $790.00 / $790.00
| Facility | | $790.00 | $790.00 | $790.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $976.65 / $1,065.29 / $1,717.38
| Professional | | $976.65 | $1,065.29 | $1,717.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.82 / $1,189.88 / $2,827.21
| Professional | | $930.82 | $1,189.88 | $2,827.21 |