- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.00 / $3,140.00 / $6,907.00
| Facility | | $3,140.00 | $3,140.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.92 / $687.56 / $687.56
| Professional | | $608.92 | $687.56 | $687.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.37 / $732.65 / $1,227.69
| Professional | | $600.37 | $732.65 | $1,227.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.00 / $143.00 / $143.00
| Facility | | $143.00 | $143.00 | $143.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.97 / $667.30 / $1,497.44
| Professional | | $586.97 | $667.30 | $1,497.44 |