- 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
- $1,098.16 / $1,098.16 / $1,177.68
| Professional | | $1,098.16 | $1,098.16 | $1,177.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $959.43 / $1,279.72 / $1,697.25
| Professional | | $959.43 | $1,279.72 | $1,697.25 |
- 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
- $1,020.37 / $1,173.58 / $2,318.91
| Professional | | $1,020.37 | $1,173.58 | $2,318.91 |