- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,726.72 / $1,726.72 / $1,726.72
| Facility | | $1,726.72 | $1,726.72 | $1,726.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,726.72 / $1,726.72 / $1,726.72
| Professional | | $1,726.72 | $1,726.72 | $1,726.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.80 / $8.01 / $10.92
| Professional | | $6.80 | $8.01 | $10.92 |
- 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
- $330.80 / $435.50 / $447.50
| Professional | | $330.80 | $435.50 | $447.50 |