- 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
- $1,423.80 / $1,620.68 / $1,620.68
| Professional | | $1,423.80 | $1,620.68 | $1,620.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.41 / $1,675.00 / $2,925.04
| Professional | | $1,426.41 | $1,675.00 | $2,925.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,170.00 / $5,170.00 / $5,170.00
| Facility | | $5,170.00 | $5,170.00 | $5,170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.35 / $1,774.26 / $3,717.16
| Professional | | $1,359.35 | $1,774.26 | $3,717.16 |