- 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
- $1,975.01 / $2,100.15 / $2,100.15
| Professional | | $1,975.01 | $2,100.15 | $2,100.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,834.50 / $2,144.53 / $4,002.02
| Professional | | $1,834.50 | $2,144.53 | $4,002.02 |
- 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
- $1,689.27 / $2,049.73 / $4,981.71
| Professional | | $1,689.27 | $2,049.73 | $4,981.71 |