- 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
- $1,146.18 / $1,211.32 / $1,211.32
| Professional | | $1,146.18 | $1,211.32 | $1,211.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.65 / $1,161.29 / $2,211.03
| Professional | | $1,015.65 | $1,161.29 | $2,211.03 |
- 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
- $1,048.49 / $1,270.24 / $2,908.18
| Professional | | $1,048.49 | $1,270.24 | $2,908.18 |