- 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
- $984.44 / $1,122.46 / $1,122.46
| Professional | | $984.44 | $1,122.46 | $1,122.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $992.13 / $1,167.83 / $2,029.76
| Professional | | $992.13 | $1,167.83 | $2,029.76 |
- 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
- $941.04 / $1,069.25 / $2,569.38
| Professional | | $941.04 | $1,069.25 | $2,569.38 |