- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,063.33 / $1,184.86 / $7,204.01
| Facility | | $1,063.33 | $1,184.86 | $7,204.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,184.86 / $1,184.86 / $1,215.25
| Professional | | $1,184.86 | $1,184.86 | $1,215.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,519.06 / $1,595.01 / $2,096.30
| Professional | | $1,519.06 | $1,595.01 | $2,096.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,760.74 / $3,742.21 / $8,661.39
| Facility | | $2,760.74 | $3,742.21 | $8,661.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,184.86 / $1,519.06 / $1,919.49
| Facility | | $1,184.86 | $1,519.06 | $1,919.49 |
- 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
- $638.01 / $911.44 / $1,383.27
| Professional | | $638.01 | $911.44 | $1,383.27 |