- 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
- $2,439.39 / $2,773.48 / $2,773.48
| Professional | | $2,439.39 | $2,773.48 | $2,773.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,139.62 / $2,729.97 / $4,847.35
| Professional | | $2,139.62 | $2,729.97 | $4,847.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,170.00 / $5,170.00 / $5,170.00
| Facility | | $5,170.00 | $5,170.00 | $5,170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.72 / $2,739.87 / $6,378.21
| Professional | | $2,031.72 | $2,739.87 | $6,378.21 |