- 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
- $1,262.68 / $1,276.07 / $1,483.83
| Professional | | $1,262.68 | $1,276.07 | $1,483.83 |
- 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
- $1,101.92 / $1,360.49 / $2,192.52
| Professional | | $1,101.92 | $1,360.49 | $2,192.52 |
- 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
- $1,067.06 / $1,304.35 / $2,931.28
| Professional | | $1,067.06 | $1,304.35 | $2,931.28 |