- 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
- $2,050.59 / $2,535.94 / $2,743.74
| Professional | | $2,050.59 | $2,535.94 | $2,743.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,258.94 / $3,117.05 / $5,055.47
| Professional | | $2,258.94 | $3,117.05 | $5,055.47 |
- 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
- $2,139.42 / $2,828.44 / $6,550.06
| Professional | | $2,139.42 | $2,828.44 | $6,550.06 |