- 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
- $2,225.33 / $2,364.46 / $2,364.46
| Professional | | $2,225.33 | $2,364.46 | $2,364.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,008.87 / $2,341.66 / $4,304.67
| Professional | | $2,008.87 | $2,341.66 | $4,304.67 |
- 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
- $2,007.77 / $2,383.19 / $5,623.19
| Professional | | $2,007.77 | $2,383.19 | $5,623.19 |