- 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
- $1,191.85 / $1,270.26 / $1,270.26
| Professional | | $1,191.85 | $1,270.26 | $1,270.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.04 / $1,235.10 / $2,177.81
| Professional | | $1,112.04 | $1,235.10 | $2,177.81 |
- 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
- $1,051.83 / $1,249.84 / $2,978.91
| Professional | | $1,051.83 | $1,249.84 | $2,978.91 |