- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,900.20 / $3,477.37 / $3,857.41
| Facility | | $1,900.20 | $3,477.37 | $3,857.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,501.16 / $3,477.37 / $3,857.41
| Professional | | $1,501.16 | $3,477.37 | $3,857.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,900.20 / $1,900.20 / $1,900.20
| Facility | | $1,900.20 | $1,900.20 | $1,900.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.20 / $1,900.20 / $1,900.20
| Professional | | $1,900.20 | $1,900.20 | $1,900.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $42.50
| Professional | | $17.00 | $20.00 | $42.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.08 / $1,140.11 / $3,230.34
| Professional | | $798.08 | $1,140.11 | $3,230.34 |