- 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
- $1,480.02 / $1,519.77 / $1,519.77
| Professional | | $1,480.02 | $1,519.77 | $1,519.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.27 / $1,864.47 / $2,632.24
| Professional | | $1,310.27 | $1,864.47 | $2,632.24 |
- 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
- $1,250.51 / $1,636.19 / $3,386.76
| Professional | | $1,250.51 | $1,636.19 | $3,386.76 |