- 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
- $2,681.94 / $2,848.04 / $2,848.04
| Professional | | $2,681.94 | $2,848.04 | $2,848.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,604.87 / $3,002.80 / $5,423.87
| Professional | | $2,604.87 | $3,002.80 | $5,423.87 |
- 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
- $2,482.67 / $2,988.66 / $6,804.71
| Professional | | $2,482.67 | $2,988.66 | $6,804.71 |