- 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
- $1,593.21 / $1,812.33 / $1,812.33
| Professional | | $1,593.21 | $1,812.33 | $1,812.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,600.62 / $2,081.16 / $3,356.81
| Professional | | $1,600.62 | $2,081.16 | $3,356.81 |
- 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
- $1,556.58 / $2,436.28 / $4,164.14
| Professional | | $1,556.58 | $2,436.28 | $4,164.14 |