- 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
- $577.60 / $577.60 / $577.60
| Professional | | $577.60 | $577.60 | $577.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.72 / $1,373.15 / $1,602.01
| Professional | | $1,258.72 | $1,373.15 | $1,602.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $2,912.00 / $2,912.00
| Facility | | $2,912.00 | $2,912.00 | $2,912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.93 / $1,656.06 / $1,734.44
| Professional | | $905.93 | $1,656.06 | $1,734.44 |