- 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 / $3,135.93
| Professional | | $1,726.72 | $1,726.72 | $3,135.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,040.58 / $1,632.34 / $3,140.82
| Facility | | $1,040.58 | $1,632.34 | $3,140.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,726.72 / $1,726.72 / $3,135.93
| Facility | | $1,726.72 | $1,726.72 | $3,135.93 |