- 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
- $1,138.65 / $1,297.16 / $1,297.16
| Professional | | $1,138.65 | $1,297.16 | $1,297.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.03 / $1,352.37 / $2,352.63
| Professional | | $1,143.03 | $1,352.37 | $2,352.63 |
- 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
- $1,099.08 / $1,361.05 / $2,971.64
| Professional | | $1,099.08 | $1,361.05 | $2,971.64 |