- 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
- $1,086.13 / $1,236.27 / $1,236.27
| Professional | | $1,086.13 | $1,236.27 | $1,236.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,060.26 / $1,273.89 / $2,201.05
| Professional | | $1,060.26 | $1,273.89 | $2,201.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.00 / $2,530.00 / $2,530.00
| Facility | | $2,530.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.98 / $1,250.61 / $2,847.46
| Professional | | $1,010.98 | $1,250.61 | $2,847.46 |