- 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
- $192.80 / $192.80 / $192.80
| Professional | | $192.80 | $192.80 | $192.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.31 / $320.31 / $452.21
| Professional | | $320.31 | $320.31 | $452.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $401.43 / $437.93 / $510.92
| Professional | | $401.43 | $437.93 | $510.92 |
- 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
- $320.31 / $449.13 / $528.16
| Professional | | $320.31 | $449.13 | $528.16 |