- 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
- $1,353.12 / $1,361.36 / $1,582.72
| Professional | | $1,353.12 | $1,361.36 | $1,582.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,151.00 / $2,151.00 / $2,151.00
| Facility | | $2,151.00 | $2,151.00 | $2,151.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.25 / $1,467.84 / $2,333.08
| Professional | | $1,160.25 | $1,467.84 | $2,333.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $324.00 / $960.00 / $960.00
| Facility | | $324.00 | $960.00 | $960.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.20 / $1,395.73 / $3,132.15
| Professional | | $1,108.20 | $1,395.73 | $3,132.15 |