- 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
- $1,883.24 / $2,002.74 / $5,072.43
| Professional | | $1,883.24 | $2,002.74 | $5,072.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,800.46 / $2,060.04 / $3,841.43
| Professional | | $1,800.46 | $2,060.04 | $3,841.43 |
- 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
- $1,732.59 / $2,261.52 / $4,749.68
| Professional | | $1,732.59 | $2,261.52 | $4,749.68 |