- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,862.09 / $1,862.09
| Facility | | $1,412.54 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $3,467.37
| Professional | | $1,862.09 | $1,862.09 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $34.67 / $34.67
| Facility | | $34.67 | $34.67 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $616.60 / $6,760.83
| Professional | | $338.84 | $616.60 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |