- 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
- $1,120.32 / $1,274.60 / $1,274.60
| Professional | | $1,120.32 | $1,274.60 | $1,274.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.95 / $1,308.29 / $2,219.92
| Professional | | $1,119.95 | $1,308.29 | $2,219.92 |
- 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
- $1,060.43 / $1,310.96 / $2,930.06
| Professional | | $1,060.43 | $1,310.96 | $2,930.06 |