- 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
- $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 / $2,417.41
| Facility | | $1,726.72 | $1,726.72 | $2,417.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.80 / $351.80 / $447.50
| Professional | | $351.80 | $351.80 | $447.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $601.59 / $601.59 / $611.83
| Facility | | $601.59 | $601.59 | $611.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |