- 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
- $623.98 / $723.36 / $723.36
| Professional | | $623.98 | $723.36 | $723.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.78 / $740.88 / $1,250.26
| Professional | | $624.78 | $740.88 | $1,250.26 |
- 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
- $583.13 / $748.37 / $1,591.15
| Professional | | $583.13 | $748.37 | $1,591.15 |