- 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
- $411.81 / $411.81 / $411.81
| Professional | | $411.81 | $411.81 | $411.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.78 / $637.35 / $763.80
| Professional | | $500.78 | $637.35 | $763.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.00 / $2,446.00 / $2,446.00
| Facility | | $2,446.00 | $2,446.00 | $2,446.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.11 / $698.76 / $763.40
| Professional | | $524.11 | $698.76 | $763.40 |