- 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
- $916.47 / $1,073.47 / $1,073.47
| Professional | | $916.47 | $1,073.47 | $1,073.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.54 / $1,264.25 / $1,787.75
| Professional | | $901.54 | $1,264.25 | $1,787.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,188.37 / $9,188.37 / $9,188.37
| Facility | | $9,188.37 | $9,188.37 | $9,188.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.56 / $1,258.60 / $2,253.09
| Professional | | $972.56 | $1,258.60 | $2,253.09 |