- 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
- $1,302.11 / $1,387.52 / $1,387.52
| Professional | | $1,302.11 | $1,387.52 | $1,387.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.49 / $1,347.04 / $2,439.36
| Professional | | $1,168.49 | $1,347.04 | $2,439.36 |
- 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
- $1,125.03 / $1,381.96 / $3,258.88
| Professional | | $1,125.03 | $1,381.96 | $3,258.88 |