- 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
- $846.44 / $965.74 / $965.74
| Professional | | $846.44 | $965.74 | $965.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.66 / $1,001.89 / $1,745.77
| Professional | | $852.66 | $1,001.89 | $1,745.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,000.00 / $3,000.00 / $5,170.00
| Facility | | $3,000.00 | $3,000.00 | $5,170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.17 / $967.26 / $2,207.77
| Professional | | $803.17 | $967.26 | $2,207.77 |