- 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
- Facility
- Modifier
- Low / Median / High Price
- $1,197.46 / $1,197.46 / $1,197.46
| Facility | | $1,197.46 | $1,197.46 | $1,197.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $572.70 / $572.70 / $572.70
| Facility | | $572.70 | $572.70 | $572.70 |