- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,244.36
| Facility | | $7,244.36 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $954.99 / $2,041.74
| Professional | | $776.25 | $954.99 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $954.99 / $1,412.54
| Professional | | $707.95 | $954.99 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $870.96 / $1,380.38
| Professional | | $707.95 | $870.96 | $1,380.38 |