- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,799.45 / $1,799.45 / $2,374.87
| Facility | | $1,799.45 | $1,799.45 | $2,374.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,374.87 / $2,374.87 / $2,374.87
| Professional | | $2,374.87 | $2,374.87 | $2,374.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,374.87 / $2,374.87 / $3,206.07
| Facility | | $2,374.87 | $2,374.87 | $3,206.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,374.87 / $2,374.87 / $2,374.87
| Professional | | $2,374.87 | $2,374.87 | $2,374.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |