- 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
- $1,213.94 / $1,382.19 / $1,382.19
| Professional | | $1,213.94 | $1,382.19 | $1,382.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,218.43 / $1,443.15 / $2,503.21
| Professional | | $1,218.43 | $1,443.15 | $2,503.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,783.00 / $2,783.00 / $2,783.00
| Facility | | $2,783.00 | $2,783.00 | $2,783.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.32 / $1,377.27 / $3,171.61
| Professional | | $1,090.32 | $1,377.27 | $3,171.61 |