- 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
- $1,063.09 / $1,231.65 / $1,231.65
| Professional | | $1,063.09 | $1,231.65 | $1,231.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $999.42 / $1,173.53 / $2,038.28
| Professional | | $999.42 | $1,173.53 | $2,038.28 |
- 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
- $882.15 / $1,081.58 / $2,714.20
| Professional | | $882.15 | $1,081.58 | $2,714.20 |