- 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
- $2,019.35 / $2,019.35 / $2,175.04
| Professional | | $2,019.35 | $2,019.35 | $2,175.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.19 / $2,297.98 / $2,692.24
| Professional | | $1,783.19 | $2,297.98 | $2,692.24 |
- 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
- $1,840.46 / $2,203.17 / $4,262.13
| Professional | | $1,840.46 | $2,203.17 | $4,262.13 |