- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,775.00 / $7,961.62 / $7,961.62
| Facility | | $3,775.00 | $7,961.62 | $7,961.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,775.00 / $7,961.62 / $7,961.62
| Professional | | $3,775.00 | $7,961.62 | $7,961.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.01 / $20.01 / $20.01
| Professional | | $20.01 | $20.01 | $20.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,270.88 / $4,270.88 / $4,270.88
| Professional | | $4,270.88 | $4,270.88 | $4,270.88 |