- 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
- $1,704.06 / $1,704.06 / $1,836.71
| Professional | | $1,704.06 | $1,704.06 | $1,836.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.51 / $1,939.54 / $2,258.48
| Professional | | $1,506.51 | $1,939.54 | $2,258.48 |
- 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
- $1,552.55 / $1,756.23 / $3,595.37
| Professional | | $1,552.55 | $1,756.23 | $3,595.37 |