- 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
- $2,574.65 / $2,574.65 / $2,750.83
| Professional | | $2,574.65 | $2,574.65 | $2,750.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,234.69 / $2,948.21 / $3,478.35
| Professional | | $2,234.69 | $2,948.21 | $3,478.35 |
- 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
- $2,284.48 / $2,726.66 / $6,033.35
| Professional | | $2,284.48 | $2,726.66 | $6,033.35 |