- 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
- $1,447.20 / $1,540.69 / $1,540.69
| Professional | | $1,447.20 | $1,540.69 | $1,540.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.02 / $1,687.83 / $2,937.79
| Professional | | $1,386.02 | $1,687.83 | $2,937.79 |
- 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
- $1,308.25 / $1,558.35 / $3,634.45
| Professional | | $1,308.25 | $1,558.35 | $3,634.45 |