- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,616.00 / $5,616.00 / $5,616.00
| Facility | | $5,616.00 | $5,616.00 | $5,616.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.02 / $118.02 / $239.82
| Professional | | $118.02 | $118.02 | $239.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.61 / $482.61 / $482.61
| Facility | | $482.61 | $482.61 | $482.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.22 / $410.22 / $482.61
| Professional | | $410.22 | $410.22 | $482.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.06 / $225.95 / $385.24
| Professional | | $150.06 | $225.95 | $385.24 |