- 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
- $1,826.27 / $2,072.09 / $2,072.09
| Professional | | $1,826.27 | $2,072.09 | $2,072.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.77 / $2,177.67 / $3,856.73
| Professional | | $1,630.77 | $2,177.67 | $3,856.73 |
- 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
- $1,771.10 / $2,461.41 / $4,788.62
| Professional | | $1,771.10 | $2,461.41 | $4,788.62 |