- 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
- $2,857.25 / $3,242.23 / $3,242.23
| Professional | | $2,857.25 | $3,242.23 | $3,242.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,854.77 / $3,429.82 / $6,028.43
| Professional | | $2,854.77 | $3,429.82 | $6,028.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,000.00 / $3,000.00 / $5,170.00
| Facility | | $3,000.00 | $3,000.00 | $5,170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,603.69 / $3,724.11 / $7,617.96
| Professional | | $2,603.69 | $3,724.11 | $7,617.96 |