- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,111.00 / $1,111.00 / $1,111.00
| Facility | | $1,111.00 | $1,111.00 | $1,111.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.82 / $443.71 / $1,151.72
| Professional | | $420.82 | $443.71 | $1,151.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,040.58 / $1,632.34 / $3,140.82
| Facility | | $1,040.58 | $1,632.34 | $3,140.82 |
- 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
- $420.82 / $708.24 / $2,046.71
| Facility | | $420.82 | $708.24 | $2,046.71 |