- 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
- $1,412.08 / $1,412.08 / $1,523.44
| Professional | | $1,412.08 | $1,412.08 | $1,523.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.31 / $1,609.16 / $1,970.86
| Professional | | $1,249.31 | $1,609.16 | $1,970.86 |
- 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
- $1,237.86 / $1,491.51 / $3,300.31
| Professional | | $1,237.86 | $1,491.51 | $3,300.31 |