- 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
- $2,209.42 / $2,503.36 / $2,503.36
| Professional | | $2,209.42 | $2,503.36 | $2,503.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,499.52 / $2,314.46 / $4,561.63
| Professional | | $1,499.52 | $2,314.46 | $4,561.63 |
- 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
- $1,387.36 / $2,143.19 / $5,796.26
| Professional | | $1,387.36 | $2,143.19 | $5,796.26 |