- 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
- $646.65 / $741.58 / $741.58
| Professional | | $646.65 | $741.58 | $741.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.87 / $796.52 / $1,339.32
| Professional | | $663.87 | $796.52 | $1,339.32 |
- 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
- $614.97 / $756.74 / $1,686.02
| Professional | | $614.97 | $756.74 | $1,686.02 |