- 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
- $1,725.91 / $1,836.19 / $1,836.19
| Professional | | $1,725.91 | $1,836.19 | $1,836.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,683.50 / $1,945.89 / $3,501.04
| Professional | | $1,683.50 | $1,945.89 | $3,501.04 |
- 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
- $1,584.19 / $1,907.65 / $4,343.41
| Professional | | $1,584.19 | $1,907.65 | $4,343.41 |