- 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
- $2,524.89 / $2,681.46 / $2,681.46
| Professional | | $2,524.89 | $2,681.46 | $2,681.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,456.78 / $2,871.87 / $5,165.76
| Professional | | $2,456.78 | $2,871.87 | $5,165.76 |
- 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
- $2,219.58 / $2,665.52 / $6,392.83
| Professional | | $2,219.58 | $2,665.52 | $6,392.83 |