- 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
- $2,152.92 / $2,430.07 / $2,430.07
| Professional | | $2,152.92 | $2,430.07 | $2,430.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,034.71 / $2,233.94 / $4,073.20
| Professional | | $2,034.71 | $2,233.94 | $4,073.20 |
- 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
- $1,951.52 / $2,607.61 / $5,629.38
| Professional | | $1,951.52 | $2,607.61 | $5,629.38 |