- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,133.39 / $5,133.39 / $5,133.39
| Facility | | $5,133.39 | $5,133.39 | $5,133.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,133.39 / $5,133.39 / $6,850.00
| Professional | | $5,133.39 | $5,133.39 | $6,850.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,209.41 / $5,612.55 / $7,484.00
| Professional | | $4,209.41 | $5,612.55 | $7,484.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $984.80 / $1,016.22 / $10,162.20
| Facility | | $984.80 | $1,016.22 | $10,162.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |