- 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
- $2,335.53 / $2,739.82 / $2,739.82
| Professional | | $2,335.53 | $2,739.82 | $2,739.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.19 / $3,173.84 / $4,562.85
| Professional | | $2,306.19 | $3,173.84 | $4,562.85 |
- 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
- $2,385.33 / $2,880.67 / $5,664.44
| Professional | | $2,385.33 | $2,880.67 | $5,664.44 |