- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,316.00 / $6,316.00 / $6,907.00
| Facility | | $6,316.00 | $6,316.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.08 / $1,133.08 / $1,228.77
| Professional | | $1,133.08 | $1,133.08 | $1,228.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.05 / $1,262.25 / $2,237.98
| Professional | | $1,076.05 | $1,262.25 | $2,237.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.00 / $2,530.00 / $2,530.00
| Facility | | $2,530.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.64 / $1,336.92 / $2,829.85
| Professional | | $1,046.64 | $1,336.92 | $2,829.85 |