- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,563.00 / $1,563.00 / $1,563.00
| Facility | | $1,563.00 | $1,563.00 | $1,563.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,563.00 / $1,563.00 / $1,563.00
| Professional | | $1,563.00 | $1,563.00 | $1,563.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.47 / $327.16 / $809.07
| Facility | | $138.47 | $327.16 | $809.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.63 / $173.10 / $408.94
| Professional | | $140.63 | $173.10 | $408.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,563.00 / $1,719.30 / $3,307.25
| Facility | | $1,563.00 | $1,719.30 | $3,307.25 |