- 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
- $1,023.63 / $1,166.18 / $1,166.18
| Professional | | $1,023.63 | $1,166.18 | $1,166.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.03 / $1,221.67 / $2,161.17
| Professional | | $1,031.03 | $1,221.67 | $2,161.17 |
- 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
- $988.67 / $1,391.84 / $2,673.12
| Professional | | $988.67 | $1,391.84 | $2,673.12 |