- 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
- $1,799.82 / $2,043.53 / $2,043.53
| Professional | | $1,799.82 | $2,043.53 | $2,043.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,800.81 / $2,327.44 / $3,805.32
| Professional | | $1,800.81 | $2,327.44 | $3,805.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,783.00 / $2,783.00 / $2,783.00
| Facility | | $2,783.00 | $2,783.00 | $2,783.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.06 / $2,617.54 / $4,792.77
| Professional | | $1,763.06 | $2,617.54 | $4,792.77 |