- 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
- $1,067.23 / $1,219.89 / $1,219.89
| Professional | | $1,067.23 | $1,219.89 | $1,219.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.41 / $1,261.73 / $2,230.62
| Professional | | $1,075.41 | $1,261.73 | $2,230.62 |
- 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
- $1,031.84 / $1,313.00 / $2,789.86
| Professional | | $1,031.84 | $1,313.00 | $2,789.86 |