- 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
- $1,386.44 / $1,575.93 / $1,575.93
| Professional | | $1,386.44 | $1,575.93 | $1,575.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.64 / $1,643.65 / $2,874.09
| Professional | | $1,363.64 | $1,643.65 | $2,874.09 |
- 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
- $1,265.27 / $1,680.23 / $3,691.27
| Professional | | $1,265.27 | $1,680.23 | $3,691.27 |