- 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
- $1,243.60 / $1,243.60 / $1,315.50
| Professional | | $1,243.60 | $1,243.60 | $1,315.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.94 / $1,391.53 / $1,499.33
| Professional | | $1,044.94 | $1,391.53 | $1,499.33 |
- 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
- $954.74 / $1,231.19 / $2,847.54
| Professional | | $954.74 | $1,231.19 | $2,847.54 |