- 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
- $2,264.69 / $2,406.15 / $2,406.15
| Professional | | $2,264.69 | $2,406.15 | $2,406.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.91 / $2,439.14 / $4,557.71
| Professional | | $2,122.91 | $2,439.14 | $4,557.71 |
- 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
- $1,933.79 / $2,327.46 / $5,722.07
| Professional | | $1,933.79 | $2,327.46 | $5,722.07 |