- 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
- $1,141.91 / $1,199.97 / $1,199.97
| Professional | | $1,141.91 | $1,199.97 | $1,199.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.09 / $1,324.85 / $2,333.77
| Professional | | $1,092.09 | $1,324.85 | $2,333.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,170.00 / $5,170.00 / $5,170.00
| Facility | | $5,170.00 | $5,170.00 | $5,170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.13 / $1,383.54 / $2,850.10
| Professional | | $1,054.13 | $1,383.54 | $2,850.10 |