- 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
- $1,551.12 / $1,765.94 / $1,765.94
| Professional | | $1,551.12 | $1,765.94 | $1,765.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $919.73 / $919.73 / $919.73
| Facility | | $919.73 | $919.73 | $919.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,558.54 / $2,050.28 / $3,283.52
| Professional | | $1,558.54 | $2,050.28 | $3,283.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,485.00 / $1,485.00 / $1,485.00
| Facility | | $1,485.00 | $1,485.00 | $1,485.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,592.91 / $2,345.80 / $4,053.48
| Professional | | $1,592.91 | $2,345.80 | $4,053.48 |