- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,907.00 / $6,907.00 / $7,265.00
| Facility | | $6,907.00 | $6,907.00 | $7,265.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.73 / $1,621.03 / $1,621.03
| Professional | | $1,392.73 | $1,621.03 | $1,621.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.79 / $1,911.54 / $2,699.64
| Professional | | $1,365.79 | $1,911.54 | $2,699.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,321.41 / $5,321.41 / $5,321.41
| Facility | | $5,321.41 | $5,321.41 | $5,321.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,430.90 / $1,733.17 / $3,420.09
| Professional | | $1,430.90 | $1,733.17 | $3,420.09 |