- 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
- $245.97 / $320.70 / $320.70
| Professional | | $245.97 | $320.70 | $320.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,732.57 / $1,732.57 / $1,732.57
| Facility | | $1,732.57 | $1,732.57 | $1,732.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,200.00
| Facility | | $2,200.00 | $2,200.00 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.37 / $289.11 / $636.04
| Professional | | $220.37 | $289.11 | $636.04 |