- 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
- $1,207.48 / $1,277.76 / $1,732.42
| Professional | | $1,207.48 | $1,277.76 | $1,732.42 |
- 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
- $1,030.45 / $1,312.47 / $2,178.67
| Professional | | $1,030.45 | $1,312.47 | $2,178.67 |
- 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
- $1,043.75 / $1,283.33 / $2,904.37
| Professional | | $1,043.75 | $1,283.33 | $2,904.37 |