- 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
- $976.42 / $976.42 / $1,060.69
| Professional | | $976.42 | $976.42 | $1,060.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.38 / $1,118.13 / $1,301.29
| Professional | | $872.38 | $1,118.13 | $1,301.29 |
- 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
- $855.50 / $1,033.00 / $2,285.75
| Professional | | $855.50 | $1,033.00 | $2,285.75 |