- 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
- $4,079.94 / $4,301.71 / $4,301.71
| Professional | | $4,079.94 | $4,301.71 | $4,301.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,141.35 / $5,890.78 / $7,926.14
| Professional | | $4,141.35 | $5,890.78 | $7,926.14 |
- 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
- $4,072.77 / $5,400.34 / $10,619.03
| Professional | | $4,072.77 | $5,400.34 | $10,619.03 |