- 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
- $1,475.98 / $1,483.50 / $2,001.13
| Professional | | $1,475.98 | $1,483.50 | $2,001.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,151.00 / $2,151.00 / $2,151.00
| Facility | | $2,151.00 | $2,151.00 | $2,151.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.35 / $1,611.64 / $2,452.21
| Professional | | $1,205.35 | $1,611.64 | $2,452.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $324.00 / $960.00 / $960.00
| Facility | | $324.00 | $960.00 | $960.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.82 / $1,500.19 / $3,415.70
| Professional | | $1,205.82 | $1,500.19 | $3,415.70 |