- 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
- $2,069.96 / $2,069.96 / $2,228.11
| Professional | | $2,069.96 | $2,069.96 | $2,228.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,785.32 / $2,357.85 / $2,754.22
| Professional | | $1,785.32 | $2,357.85 | $2,754.22 |
- 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
- $1,859.20 / $1,931.94 / $4,385.99
| Professional | | $1,859.20 | $1,931.94 | $4,385.99 |