- 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
- $1,381.25 / $1,448.91 / $1,448.91
| Professional | | $1,381.25 | $1,448.91 | $1,448.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.36 / $1,587.11 / $2,760.00
| Professional | | $1,283.36 | $1,587.11 | $2,760.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $960.00
| Facility | | $150.00 | $150.00 | $960.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.28 / $1,597.78 / $3,450.74
| Professional | | $1,276.28 | $1,597.78 | $3,450.74 |