- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $1,227.04
| Facility | | $1,227.04 | $1,227.04 | $1,227.04 |
- 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
- $436.18 / $585.78 / $848.51
| Facility | | $436.18 | $585.78 | $848.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $1,411.10
| Facility | | $1,227.04 | $1,227.04 | $1,411.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $601.22 / $601.22 / $601.22
| Facility | | $601.22 | $601.22 | $601.22 |