- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,330.14 / $1,482.16 / $9,011.53
| Facility | | $1,330.14 | $1,482.16 | $9,011.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.16 / $1,482.16 / $1,520.16
| Professional | | $1,482.16 | $1,482.16 | $1,520.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.20 / $1,900.20 / $2,598.52
| Professional | | $1,900.20 | $1,900.20 | $2,598.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,453.42 / $4,681.14 / $10,834.56
| Facility | | $3,453.42 | $4,681.14 | $10,834.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,330.14 / $1,900.20 / $2,356.25
| Facility | | $1,330.14 | $1,900.20 | $2,356.25 |
- 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
- $798.08 / $1,083.83 / $1,730.34
| Professional | | $798.08 | $1,083.83 | $1,730.34 |