- 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
- $1,344.58 / $1,529.37 / $1,529.37
| Professional | | $1,344.58 | $1,529.37 | $1,529.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.78 / $1,560.08 / $2,762.27
| Professional | | $893.78 | $1,560.08 | $2,762.27 |
- 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
- $815.53 / $1,302.28 / $3,521.04
| Professional | | $815.53 | $1,302.28 | $3,521.04 |