- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,726.72 / $1,726.72 / $2,179.05
| Facility | | $1,726.72 | $1,726.72 | $2,179.05 |
- 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
- $963.57 / $1,152.99 / $1,457.71
| Facility | | $963.57 | $1,152.99 | $1,457.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $345.40
| Professional | | $100.00 | $200.00 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $658.86 / $658.86 / $658.86
| Facility | | $658.86 | $658.86 | $658.86 |