- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,907.00 / $6,907.00 / $15,648.00
| Facility | | $6,907.00 | $6,907.00 | $15,648.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.01 / $1,409.01 / $1,519.68
| Professional | | $1,409.01 | $1,409.01 | $1,519.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.71 / $1,603.29 / $1,866.17
| Professional | | $1,248.71 | $1,603.29 | $1,866.17 |
- 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
- $1,245.42 / $1,477.16 / $3,281.52
| Professional | | $1,245.42 | $1,477.16 | $3,281.52 |