- 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
- $1,094.78 / $1,246.14 / $1,246.14
| Professional | | $1,094.78 | $1,246.14 | $1,246.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.96 / $1,283.01 / $2,252.27
| Professional | | $1,098.96 | $1,283.01 | $2,252.27 |
- 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
- $1,038.72 / $1,188.70 / $2,861.58
| Professional | | $1,038.72 | $1,188.70 | $2,861.58 |