- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,700.15 / $1,700.15 / $1,700.15
| Facility | | $1,700.15 | $1,700.15 | $1,700.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.15 / $1,700.15 / $1,700.15
| Professional | | $1,700.15 | $1,700.15 | $1,700.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.33 / $303.33 / $303.33
| Facility | | $303.33 | $303.33 | $303.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $257.83 / $3,609.38
| Professional | | $192.51 | $257.83 | $3,609.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.71 / $211.54 / $2,666.88
| Professional | | $129.71 | $211.54 | $2,666.88 |