- 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
- $2,129.06 / $2,262.37 / $5,635.28
| Professional | | $2,129.06 | $2,262.37 | $5,635.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.63 / $2,240.00 / $4,313.04
| Professional | | $1,983.63 | $2,240.00 | $4,313.04 |
- 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
- $1,910.43 / $2,359.94 / $5,465.15
| Professional | | $1,910.43 | $2,359.94 | $5,465.15 |