- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,445.52 / $2,212.46
| Facility | | $1,227.04 | $1,445.52 | $2,212.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $1,227.04
| Professional | | $1,227.04 | $1,227.04 | $1,227.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $1,717.86
| Facility | | $1,227.04 | $1,227.04 | $1,717.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $601.59 / $601.59 / $611.83
| Facility | | $601.59 | $601.59 | $611.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |