- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.57 / $1,060.57 / $1,060.57
| Facility | | $1,060.57 | $1,060.57 | $1,060.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $721.00 / $1,060.57 / $1,060.57
| Professional | | $721.00 | $1,060.57 | $1,060.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $462.00 / $507.03 / $553.00
| Facility | | $462.00 | $507.03 | $553.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.03 / $77.29 / $104.92
| Professional | | $54.03 | $77.29 | $104.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $525.00 / $605.00
| Facility | | $500.00 | $525.00 | $605.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.81 / $1.81 / $1.81
| Professional | | $1.81 | $1.81 | $1.81 |