- 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
- $1,319.45 / $1,500.16 / $1,500.16
| Professional | | $1,319.45 | $1,500.16 | $1,500.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.11 / $1,393.12 / $2,722.90
| Professional | | $815.11 | $1,393.12 | $2,722.90 |
- 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
- $770.77 / $1,277.14 / $3,453.06
| Professional | | $770.77 | $1,277.14 | $3,453.06 |