- 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
- $964.06 / $990.87 / $990.87
| Professional | | $964.06 | $990.87 | $990.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.30 / $1,201.72 / $1,716.19
| Professional | | $816.30 | $1,201.72 | $1,716.19 |
- 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
- $807.12 / $1,022.61 / $2,182.25
| Professional | | $807.12 | $1,022.61 | $2,182.25 |