- 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
- $961.53 / $1,101.49 / $1,101.49
| Professional | | $961.53 | $1,101.49 | $1,101.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.47 / $1,139.33 / $1,840.20
| Professional | | $914.47 | $1,139.33 | $1,840.20 |
- 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
- $863.32 / $1,089.43 / $2,495.96
| Professional | | $863.32 | $1,089.43 | $2,495.96 |