- 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
- $2,179.35 / $2,316.25 / $2,316.25
| Professional | | $2,179.35 | $2,316.25 | $2,316.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,973.61 / $2,384.05 / $4,319.89
| Professional | | $1,973.61 | $2,384.05 | $4,319.89 |
- 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
- $1,906.58 / $2,225.94 / $5,600.89
| Professional | | $1,906.58 | $2,225.94 | $5,600.89 |