- 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
- $1,958.19 / $1,958.19 / $2,109.60
| Professional | | $1,958.19 | $1,958.19 | $2,109.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,729.57 / $2,229.03 / $2,561.71
| Professional | | $1,729.57 | $2,229.03 | $2,561.71 |
- 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
- $1,719.36 / $2,057.73 / $4,574.09
| Professional | | $1,719.36 | $2,057.73 | $4,574.09 |