- 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
- $1,227.61 / $1,399.28 / $1,399.28
| Professional | | $1,227.61 | $1,399.28 | $1,399.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.68 / $1,443.17 / $2,562.94
| Professional | | $1,217.68 | $1,443.17 | $2,562.94 |
- 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
- $1,160.22 / $1,485.82 / $3,136.96
| Professional | | $1,160.22 | $1,485.82 | $3,136.96 |