- 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
- $1,177.61 / $1,201.54 / $1,201.54
| Professional | | $1,177.61 | $1,201.54 | $1,201.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.91 / $1,468.08 / $2,081.07
| Professional | | $1,074.91 | $1,468.08 | $2,081.07 |
- 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
- $1,059.31 / $1,370.88 / $2,702.17
| Professional | | $1,059.31 | $1,370.88 | $2,702.17 |