- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,507.00 / $1,507.00 / $1,507.00
| Facility | | $1,507.00 | $1,507.00 | $1,507.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $1,507.00
| Professional | | $1,227.04 | $1,227.04 | $1,507.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.00 / $600.00 / $600.00
| Professional | | $600.00 | $600.00 | $600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,507.00 / $2,531.76
| Facility | | $1,227.04 | $1,507.00 | $2,531.76 |