- 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
- $134.41 / $153.24 / $153.24
| Professional | | $134.41 | $153.24 | $153.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.44 / $141.44 / $141.44
| Facility | | $141.44 | $141.44 | $141.44 |
- 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
- $228.36 / $327.39 / $636.04
| Professional | | $228.36 | $327.39 | $636.04 |