- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.48 / $1,770.48 / $3,762.27
| Facility | | $1,770.48 | $1,770.48 | $3,762.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.09 / $1,434.09 / $1,434.09
| Professional | | $1,434.09 | $1,434.09 | $1,434.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.20 / $33.20 / $1,150.81
| Professional | | $33.20 | $33.20 | $1,150.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.48 / $1,770.48 / $1,788.18
| Professional | | $1,770.48 | $1,770.48 | $1,788.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.48 / $1,770.48 / $2,868.18
| Facility | | $1,770.48 | $1,770.48 | $2,868.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.09 / $1,434.09 / $1,770.48
| Professional | | $1,434.09 | $1,434.09 | $1,770.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.94 / $1,062.29 / $2,655.72
| Professional | | $902.94 | $1,062.29 | $2,655.72 |