- 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
- $433.77 / $1,060.57 / $1,060.57
| Professional | | $433.77 | $1,060.57 | $1,060.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.60 / $111.92 / $111.92
| Professional | | $45.60 | $111.92 | $111.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.57 / $1,060.57 / $1,378.74
| Facility | | $1,060.57 | $1,060.57 | $1,378.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |