- 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
- $2,367.28 / $2,515.35 / $2,515.35
| Professional | | $2,367.28 | $2,515.35 | $2,515.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,305.21 / $2,734.13 / $4,866.43
| Professional | | $2,305.21 | $2,734.13 | $4,866.43 |
- 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
- $2,184.14 / $2,656.71 / $5,987.05
| Professional | | $2,184.14 | $2,656.71 | $5,987.05 |