- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,285.00 / $10,900.00 / $14,552.94
| Facility | | $9,285.00 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.00 / $1,875.00 / $1,875.00
| Professional | | $1,875.00 | $1,875.00 | $1,875.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $599.76 / $599.76 / $599.76
| Professional | | $599.76 | $599.76 | $599.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,875.00 / $1,875.00 / $2,907.00
| Facility | | $1,875.00 | $1,875.00 | $2,907.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,875.00 / $1,875.00 / $2,681.25
| Facility | | $1,875.00 | $1,875.00 | $2,681.25 |