- 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
- $124.32 / $166.33 / $166.33
| Professional | | $124.32 | $166.33 | $166.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.37 / $524.37 / $524.37
| Facility | | $524.37 | $524.37 | $524.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $440.00 / $440.00 / $440.00
| Facility | | $440.00 | $440.00 | $440.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.01 / $209.34 / $413.67
| Professional | | $157.01 | $209.34 | $413.67 |