- 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
- $1,899.04 / $2,007.61 / $2,007.61
| Professional | | $1,899.04 | $2,007.61 | $2,007.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.21 / $2,719.35 / $3,699.13
| Professional | | $1,875.21 | $2,719.35 | $3,699.13 |
- 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
- $1,784.74 / $2,421.90 / $4,762.34
| Professional | | $1,784.74 | $2,421.90 | $4,762.34 |