- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,670.07 / $1,670.07 / $1,908.65
| Facility | | $1,670.07 | $1,670.07 | $1,908.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,670.07 / $1,908.65
| Professional | | $1,590.54 | $1,670.07 | $1,908.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.32 / $5.32 / $5.32
| Professional | | $5.32 | $5.32 | $5.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,590.54
| Facility | | $1,590.54 | $1,590.54 | $1,590.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,590.54
| Professional | | $1,590.54 | $1,590.54 | $1,590.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,526.92 / $1,590.54 / $2,067.69
| Professional | | $1,526.92 | $1,590.54 | $2,067.69 |