- 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
- $1,043.82 / $1,311.32 / $1,311.32
| Professional | | $1,043.82 | $1,311.32 | $1,311.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.92 / $1,347.80 / $2,236.25
| Professional | | $1,153.92 | $1,347.80 | $2,236.25 |
- 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
- $1,027.49 / $1,320.21 / $2,778.07
| Professional | | $1,027.49 | $1,320.21 | $2,778.07 |