- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,930.50 / $3,211.65 / $3,562.65
| Facility | | $1,930.50 | $3,211.65 | $3,562.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.45 / $3,211.65 / $3,562.65
| Professional | | $1,386.45 | $3,211.65 | $3,562.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.00 / $32.00 / $32.00
| Facility | | $32.00 | $32.00 | $32.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.00 / $32.00 / $32.00
| Professional | | $32.00 | $32.00 | $32.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,140.75 / $1,140.75 / $1,197.79
| Facility | | $1,140.75 | $1,140.75 | $1,197.79 |
- 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
- $737.10 / $1,053.00 / $2,983.50
| Professional | | $737.10 | $1,053.00 | $2,983.50 |