- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,943.21 / $3,556.07 / $4,800.68
| Facility | | $1,943.21 | $3,556.07 | $4,800.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,535.14 / $1,535.14 / $1,535.14
| Professional | | $1,535.14 | $1,535.14 | $1,535.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,156.40 / $1,156.40 / $1,156.40
| Facility | | $1,156.40 | $1,156.40 | $1,156.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.40 / $1,156.40 / $1,156.40
| Professional | | $1,156.40 | $1,156.40 | $1,156.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,263.08 / $1,263.08 / $1,326.24
| Facility | | $1,263.08 | $1,263.08 | $1,326.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.00 / $40.00 / $50.00
| Professional | | $20.00 | $40.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.15 / $1,165.93 / $3,303.46
| Professional | | $816.15 | $1,165.93 | $3,303.46 |