- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,550.00 / $2,550.00 / $2,550.00
| Facility | | $2,550.00 | $2,550.00 | $2,550.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.72 / $1,751.72 / $2,550.00
| Professional | | $1,751.72 | $1,751.72 | $2,550.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,080.00 / $1,080.00 / $1,080.00
| Facility | | $1,080.00 | $1,080.00 | $1,080.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.67 / $783.67 / $783.67
| Professional | | $783.67 | $783.67 | $783.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.00 / $1,751.72 / $2,411.21
| Facility | | $24.00 | $1,751.72 | $2,411.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $55.00
| Professional | | $55.00 | $55.00 | $55.00 |