- 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
- $522.00 / $1,060.57 / $1,060.57
| Professional | | $522.00 | $1,060.57 | $1,060.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.38 / $79.23 / $79.23
| Professional | | $63.38 | $79.23 | $79.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.00 / $400.00 / $400.00
| Facility | | $400.00 | $400.00 | $400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $547.00 / $547.00 / $605.00
| Facility | | $547.00 | $547.00 | $605.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.06 / $152.05 / $191.72
| Professional | | $111.06 | $152.05 | $191.72 |