- 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
- $1,073.76 / $1,073.76 / $1,151.96
| Professional | | $1,073.76 | $1,073.76 | $1,151.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.70 / $1,233.11 / $1,429.65
| Professional | | $942.70 | $1,233.11 | $1,429.65 |
- 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
- $987.80 / $1,154.94 / $2,530.85
| Professional | | $987.80 | $1,154.94 | $2,530.85 |