- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $2,147.32
| Facility | | $1,227.04 | $1,227.04 | $2,147.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $1,303.44
| Professional | | $1,227.04 | $1,227.04 | $1,303.44 |
- 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
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $577.14 / $577.14 / $587.14
| Facility | | $577.14 | $577.14 | $587.14 |