- 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
- $703.04 / $793.02 / $793.02
| Professional | | $703.04 | $793.02 | $793.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.12 / $876.65 / $1,526.56
| Professional | | $693.12 | $876.65 | $1,526.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,783.00 / $2,783.00 / $2,783.00
| Facility | | $2,783.00 | $2,783.00 | $2,783.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.86 / $973.07 / $1,851.68
| Professional | | $684.86 | $973.07 | $1,851.68 |