- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,916.60 / $5,337.38 / $7,205.46
| Facility | | $2,916.60 | $5,337.38 | $7,205.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.00 / $74.00 / $74.00
| Facility | | $74.00 | $74.00 | $74.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.00 / $74.00 / $74.00
| Professional | | $74.00 | $74.00 | $74.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,895.79 / $1,990.58 / $2,212.39
| Facility | | $1,895.79 | $1,990.58 | $2,212.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Professional | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.97 / $1,749.96 / $4,374.89
| Professional | | $1,224.97 | $1,749.96 | $4,374.89 |