- 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
- $2,298.71 / $2,298.71 / $2,455.16
| Professional | | $2,298.71 | $2,298.71 | $2,455.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,994.79 / $2,639.95 / $3,107.07
| Professional | | $1,994.79 | $2,639.95 | $3,107.07 |
- 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
- $2,035.21 / $2,432.92 / $5,383.40
| Professional | | $2,035.21 | $2,432.92 | $5,383.40 |