- 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
- $1,064.14 / $1,214.31 / $1,214.31
| Professional | | $1,064.14 | $1,214.31 | $1,214.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.15 / $1,258.19 / $2,196.25
| Professional | | $1,074.15 | $1,258.19 | $2,196.25 |
- 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
- $1,027.93 / $1,256.16 / $2,779.26
| Professional | | $1,027.93 | $1,256.16 | $2,779.26 |