- 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
- $2,098.42 / $2,098.42 / $2,242.42
| Professional | | $2,098.42 | $2,098.42 | $2,242.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.33 / $2,368.27 / $2,569.98
| Professional | | $1,822.33 | $2,368.27 | $2,569.98 |
- 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
- $1,892.24 / $2,315.90 / $4,441.34
| Professional | | $1,892.24 | $2,315.90 | $4,441.34 |