- 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
- $1,404.19 / $1,404.19 / $1,502.11
| Professional | | $1,404.19 | $1,404.19 | $1,502.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,221.38 / $1,619.25 / $1,900.51
| Professional | | $1,221.38 | $1,619.25 | $1,900.51 |
- 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
- $1,246.02 / $1,462.96 / $3,287.00
| Professional | | $1,246.02 | $1,462.96 | $3,287.00 |