- 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
- $1,254.69 / $1,335.18 / $1,335.18
| Professional | | $1,254.69 | $1,335.18 | $1,335.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.55 / $1,424.73 / $2,544.48
| Professional | | $1,134.55 | $1,424.73 | $2,544.48 |
- 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
- $1,073.18 / $1,336.56 / $3,148.66
| Professional | | $1,073.18 | $1,336.56 | $3,148.66 |