- 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
- $1,497.84 / $1,684.01 / $1,684.01
| Professional | | $1,497.84 | $1,684.01 | $1,684.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.05 / $2,005.13 / $3,193.81
| Professional | | $1,463.05 | $2,005.13 | $3,193.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,783.00 / $2,783.00 / $2,783.00
| Facility | | $2,783.00 | $2,783.00 | $2,783.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.56 / $1,830.30 / $4,013.88
| Professional | | $1,484.56 | $1,830.30 | $4,013.88 |