- 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
- $1,802.75 / $2,047.31 / $2,047.31
| Professional | | $1,802.75 | $2,047.31 | $2,047.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,804.61 / $2,304.63 / $3,739.52
| Professional | | $1,804.61 | $2,304.63 | $3,739.52 |
- 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
- $1,745.78 / $2,792.93 / $4,720.14
| Professional | | $1,745.78 | $2,792.93 | $4,720.14 |