- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,560.41 / $1,560.41 / $1,560.41
| Facility | | $1,560.41 | $1,560.41 | $1,560.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.41 / $1,560.41 / $1,560.41
| Professional | | $1,560.41 | $1,560.41 | $1,560.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.68 / $1,365.40 / $1,629.78
| Facility | | $660.68 | $1,365.40 | $1,629.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,560.41 / $1,560.41 / $1,560.41
| Facility | | $1,560.41 | $1,560.41 | $1,560.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $55.00
| Professional | | $30.00 | $30.00 | $55.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $994.49 / $1,339.30 / $1,677.94
| Facility | | $994.49 | $1,339.30 | $1,677.94 |