- 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
- $1,307.38 / $1,314.52 / $1,528.86
| Professional | | $1,307.38 | $1,314.52 | $1,528.86 |
- 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
- $1,068.33 / $1,397.94 / $2,251.82
| Professional | | $1,068.33 | $1,397.94 | $2,251.82 |
- 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
- $1,057.55 / $1,346.65 / $3,022.32
| Professional | | $1,057.55 | $1,346.65 | $3,022.32 |