- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,338.00 / $4,338.00 / $4,338.00
| Facility | | $4,338.00 | $4,338.00 | $4,338.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,804.54 / $9,804.54 / $9,804.54
| Professional | | $9,804.54 | $9,804.54 | $9,804.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.00 / $16,569.68 / $16,569.68
| Facility | | $2,714.00 | $16,569.68 | $16,569.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,937.53 / $7,954.64 / $11,519.08
| Facility | | $5,937.53 | $7,954.64 | $11,519.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.00 / $2,714.00 / $2,714.00
| Facility | | $2,714.00 | $2,714.00 | $2,714.00 |