- 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
- $1,134.10 / $1,291.08 / $1,291.08
| Professional | | $1,134.10 | $1,291.08 | $1,291.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.54 / $1,352.85 / $2,384.25
| Professional | | $1,139.54 | $1,352.85 | $2,384.25 |
- 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
- $1,096.16 / $1,396.80 / $2,963.74
| Professional | | $1,096.16 | $1,396.80 | $2,963.74 |