- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,953.32 / $1,953.32 / $3,018.06
| Facility | | $1,953.32 | $1,953.32 | $3,018.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.02 / $439.79 / $859.34
| Facility | | $227.02 | $439.79 | $859.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $667.01 / $667.01 / $667.01
| Professional | | $667.01 | $667.01 | $667.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,953.32 / $1,953.32 / $3,018.06
| Facility | | $1,953.32 | $1,953.32 | $3,018.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $75.00
| Professional | | $30.00 | $30.00 | $75.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.00 / $1,438.00 / $1,844.00
| Facility | | $300.00 | $1,438.00 | $1,844.00 |