- 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
- $1,523.04 / $1,523.04 / $1,642.49
| Professional | | $1,523.04 | $1,523.04 | $1,642.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.59 / $1,731.40 / $2,025.02
| Professional | | $1,346.59 | $1,731.40 | $2,025.02 |
- 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
- $1,264.09 / $1,605.47 / $3,552.47
| Professional | | $1,264.09 | $1,605.47 | $3,552.47 |