- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,938.01 / $3,546.56 / $3,934.16
| Facility | | $1,938.01 | $3,546.56 | $3,934.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,531.03 / $3,546.56 / $3,934.16
| Professional | | $1,531.03 | $3,546.56 | $3,934.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $77.06 / $77.06 / $77.06
| Facility | | $77.06 | $77.06 | $77.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.06 / $77.06 / $77.06
| Professional | | $77.06 | $77.06 | $77.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,259.71 / $1,259.71 / $1,322.70
| Facility | | $1,259.71 | $1,259.71 | $1,322.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $42.50
| Professional | | $17.00 | $20.00 | $42.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.96 / $1,162.81 / $2,907.02
| Professional | | $813.96 | $1,162.81 | $2,907.02 |