- 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
- $1,068.56 / $1,090.25 / $1,090.25
| Professional | | $1,068.56 | $1,090.25 | $1,090.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $976.16 / $1,357.99 / $1,888.32
| Professional | | $976.16 | $1,357.99 | $1,888.32 |
- 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
- $919.69 / $1,332.05 / $2,451.26
| Professional | | $919.69 | $1,332.05 | $2,451.26 |