- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,835.00 / $6,835.00 / $6,907.00
| Facility | | $6,835.00 | $6,835.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.37 / $1,822.54 / $1,822.54
| Professional | | $1,544.37 | $1,822.54 | $1,822.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.03 / $1,946.05 / $3,368.51
| Professional | | $1,618.03 | $1,946.05 | $3,368.51 |
- 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
- $1,504.51 / $1,834.05 / $4,168.06
| Professional | | $1,504.51 | $1,834.05 | $4,168.06 |