- 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
- $1,281.73 / $1,458.68 / $1,477.17
| Professional | | $1,281.73 | $1,458.68 | $1,477.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.77 / $1,531.44 / $2,673.40
| Professional | | $1,285.77 | $1,531.44 | $2,673.40 |
- 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
- $1,240.56 / $1,547.77 / $3,354.16
| Professional | | $1,240.56 | $1,547.77 | $3,354.16 |