- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.48 / $3,239.98 / $3,594.08
| Facility | | $1,770.48 | $3,239.98 | $3,594.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,398.68 / $3,239.98 / $3,594.08
| Professional | | $1,398.68 | $3,239.98 | $3,594.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.48 / $1,770.48 / $1,770.48
| Facility | | $1,770.48 | $1,770.48 | $1,770.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.48 / $1,770.48 / $1,770.48
| Professional | | $1,770.48 | $1,770.48 | $1,770.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Professional | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,593.43 / $1,593.43 / $1,770.48
| Facility | | $1,593.43 | $1,593.43 | $1,770.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.60 / $1,062.29 / $3,009.82
| Professional | | $743.60 | $1,062.29 | $3,009.82 |