- 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
- $1,130.95 / $1,130.95 / $1,214.96
| Professional | | $1,130.95 | $1,130.95 | $1,214.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.63 / $1,583.94 / $1,857.07
| Professional | | $1,133.63 | $1,583.94 | $1,857.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,207.18 / $10,207.18 / $10,207.18
| Facility | | $10,207.18 | $10,207.18 | $10,207.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.64 / $1,520.12 / $2,863.86
| Professional | | $1,174.64 | $1,520.12 | $2,863.86 |