- 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
- $590.39 / $620.73 / $620.73
| Professional | | $590.39 | $620.73 | $620.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,286.21 / $1,286.21 / $1,286.21
| Facility | | $1,286.21 | $1,286.21 | $1,286.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.44 / $620.46 / $1,140.66
| Professional | | $543.44 | $620.46 | $1,140.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,200.00
| Facility | | $2,200.00 | $2,200.00 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $535.77 / $642.94 / $1,451.78
| Professional | | $535.77 | $642.94 | $1,451.78 |