- 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
- $638.57 / $739.92 / $739.92
| Professional | | $638.57 | $739.92 | $739.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.80 / $759.41 / $1,269.81
| Professional | | $638.80 | $759.41 | $1,269.81 |
- 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
- $597.12 / $751.07 / $1,630.75
| Professional | | $597.12 | $751.07 | $1,630.75 |