- 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
- $1,280.34 / $1,288.17 / $1,497.78
| Professional | | $1,280.34 | $1,288.17 | $1,497.78 |
- 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
- $1,116.24 / $1,363.18 / $2,206.82
| Professional | | $1,116.24 | $1,363.18 | $2,206.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,663.00 / $2,530.00 / $2,530.00
| Facility | | $1,663.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.16 / $1,313.46 / $2,958.38
| Professional | | $1,053.16 | $1,313.46 | $2,958.38 |