- 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
- $1,991.48 / $2,249.35 / $2,249.35
| Professional | | $1,991.48 | $2,249.35 | $2,249.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.16 / $2,126.27 / $3,580.83
| Professional | | $1,778.16 | $2,126.27 | $3,580.83 |
- 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
- $1,751.07 / $2,092.85 / $5,206.49
| Professional | | $1,751.07 | $2,092.85 | $5,206.49 |