- 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
- $1,528.62 / $1,553.34 / $1,553.34
| Professional | | $1,528.62 | $1,553.34 | $1,553.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.31 / $2,007.69 / $2,839.43
| Professional | | $1,482.31 | $2,007.69 | $2,839.43 |
- 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
- $1,450.57 / $2,374.28 / $3,806.97
| Professional | | $1,450.57 | $2,374.28 | $3,806.97 |