- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,950.00 / $1,950.00 / $1,950.00
| Professional | | $1,950.00 | $1,950.00 | $1,950.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $643.05 / $808.76 / $2,443.63
| Facility | | $643.05 | $808.76 | $2,443.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.14 / $693.53 / $1,343.58
| Professional | | $258.14 | $693.53 | $1,343.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $643.05 / $808.76 / $2,443.63
| Facility | | $643.05 | $808.76 | $2,443.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.55 / $693.53 / $1,061.32
| Professional | | $420.55 | $693.53 | $1,061.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.66 / $1,290.55 / $2,666.39
| Professional | | $865.66 | $1,290.55 | $2,666.39 |