- 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
- $628.75 / $719.97 / $719.97
| Professional | | $628.75 | $719.97 | $719.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.48 / $754.07 / $1,298.91
| Professional | | $641.48 | $754.07 | $1,298.91 |
- 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
- $615.48 / $938.18 / $1,624.50
| Professional | | $615.48 | $938.18 | $1,624.50 |