- 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
- $1,703.88 / $1,703.88 / $1,847.26
| Professional | | $1,703.88 | $1,703.88 | $1,847.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,489.30 / $1,952.39 / $2,299.21
| Professional | | $1,489.30 | $1,952.39 | $2,299.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Facility | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.25 / $1,596.17 / $4,012.23
| Professional | | $1,272.25 | $1,596.17 | $4,012.23 |