- 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
- $1,481.50 / $1,751.12 / $1,751.12
| Professional | | $1,481.50 | $1,751.12 | $1,751.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.92 / $1,684.35 / $2,867.46
| Professional | | $1,347.92 | $1,684.35 | $2,867.46 |
- 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
- $1,243.41 / $1,564.06 / $3,980.07
| Professional | | $1,243.41 | $1,564.06 | $3,980.07 |