- 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
- $1,471.64 / $1,471.64 / $1,587.08
| Professional | | $1,471.64 | $1,471.64 | $1,587.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.83 / $1,674.89 / $1,948.05
| Professional | | $1,300.83 | $1,674.89 | $1,948.05 |
- 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
- $1,299.72 / $1,549.68 / $3,429.02
| Professional | | $1,299.72 | $1,549.68 | $3,429.02 |