- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,736.00 / $4,736.00 / $6,907.00
| Facility | | $4,736.00 | $4,736.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.60 / $766.60 / $766.60
| Professional | | $766.60 | $766.60 | $766.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.63 / $764.95 / $1,200.97
| Professional | | $697.63 | $764.95 | $1,200.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $637.38 / $923.37 / $2,031.41
| Professional | | $637.38 | $923.37 | $2,031.41 |