- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,717.63 / $2,717.63 / $2,717.63
| Facility | | $2,717.63 | $2,717.63 | $2,717.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.14 / $1,199.58 / $1,954.72
| Facility | | $327.14 | $1,199.58 | $1,954.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.87 / $602.87 / $602.87
| Facility | | $602.87 | $602.87 | $602.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $85.00 / $1,500.00
| Professional | | $60.00 | $85.00 | $1,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.87 / $602.87 / $602.87
| Facility | | $602.87 | $602.87 | $602.87 |