- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,907.00 / $6,907.00 / $7,265.00
| Facility | | $6,907.00 | $6,907.00 | $7,265.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.20 / $1,773.11 / $1,898.76
| Professional | | $1,419.20 | $1,773.11 | $1,898.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,248.00 / $1,248.00 / $1,248.00
| Facility | | $1,248.00 | $1,248.00 | $1,248.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.44 / $1,319.87 / $2,068.67
| Professional | | $1,263.44 | $1,319.87 | $2,068.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.81 / $1,436.83 / $3,441.03
| Professional | | $1,196.81 | $1,436.83 | $3,441.03 |