- 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
- $1,447.41 / $1,476.21 / $1,476.21
| Professional | | $1,447.41 | $1,476.21 | $1,476.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.03 / $1,805.84 / $2,556.80
| Professional | | $1,319.03 | $1,805.84 | $2,556.80 |
- 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
- $1,460.00 / $2,136.98 / $3,324.18
| Professional | | $1,460.00 | $2,136.98 | $3,324.18 |