- 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
- $1,552.82 / $1,651.02 / $1,651.02
| Professional | | $1,552.82 | $1,651.02 | $1,651.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.62 / $1,667.32 / $3,149.81
| Professional | | $1,385.62 | $1,667.32 | $3,149.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $960.00 / $960.00
| Facility | | $960.00 | $960.00 | $960.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,355.34 / $1,609.46 / $3,908.04
| Professional | | $1,355.34 | $1,609.46 | $3,908.04 |