- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $2,747.00 / $2,747.00
| Facility | | $2,747.00 | $2,747.00 | $2,747.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.20 / $215.20 / $215.20
| Professional | | $215.20 | $215.20 | $215.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.17 / $17.64 / $20.58
| Professional | | $16.17 | $17.64 | $20.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.00 / $2,155.00 / $2,155.00
| Facility | | $2,155.00 | $2,155.00 | $2,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.72 / $439.89 / $477.22
| Professional | | $326.72 | $439.89 | $477.22 |