- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,907.00 / $6,907.00 / $6,907.00
| Facility | | $6,907.00 | $6,907.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.76 / $1,886.91 / $1,886.91
| Professional | | $1,460.76 | $1,886.91 | $1,886.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,035.70 / $5,035.70 / $5,035.70
| Facility | | $5,035.70 | $5,035.70 | $5,035.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,200.00
| Facility | | $2,200.00 | $2,200.00 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $435.57 / $585.65 / $3,918.53
| Professional | | $435.57 | $585.65 | $3,918.53 |