- 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
- $2,096.57 / $2,228.30 / $5,278.74
| Professional | | $2,096.57 | $2,228.30 | $5,278.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,937.95 / $2,268.55 / $4,245.14
| Professional | | $1,937.95 | $2,268.55 | $4,245.14 |
- 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
- $1,809.18 / $2,141.78 / $5,295.46
| Professional | | $1,809.18 | $2,141.78 | $5,295.46 |