- 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
- $792.40 / $902.98 / $902.98
| Professional | | $792.40 | $902.98 | $902.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.25 / $926.85 / $1,605.38
| Professional | | $793.25 | $926.85 | $1,605.38 |
- 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
- $755.57 / $948.08 / $2,071.16
| Professional | | $755.57 | $948.08 | $2,071.16 |