- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,949.00 / $3,949.00 / $6,907.00
| Facility | | $3,949.00 | $3,949.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.90 / $644.64 / $644.64
| Professional | | $630.90 | $644.64 | $644.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.08 / $780.52 / $1,116.51
| Professional | | $580.08 | $780.52 | $1,116.51 |
- 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
- $570.88 / $738.78 / $1,440.32
| Professional | | $570.88 | $738.78 | $1,440.32 |