- 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
- $1,227.03 / $1,396.53 / $1,396.53
| Professional | | $1,227.03 | $1,396.53 | $1,396.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.34 / $1,486.30 / $2,530.89
| Professional | | $1,230.34 | $1,486.30 | $2,530.89 |
- 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
- $1,169.58 / $1,407.52 / $3,204.70
| Professional | | $1,169.58 | $1,407.52 | $3,204.70 |