- 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
- $2,741.14 / $2,911.18 / $2,911.18
| Professional | | $2,741.14 | $2,911.18 | $2,911.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,666.09 / $3,085.47 / $5,611.66
| Professional | | $2,666.09 | $3,085.47 | $5,611.66 |
- 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
- $2,536.94 / $3,054.10 / $6,953.70
| Professional | | $2,536.94 | $3,054.10 | $6,953.70 |