- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,041.74 / $4,466.84
| Facility | | $1,621.81 | $2,041.74 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $2,137.96
| Professional | | $1,621.81 | $1,621.81 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,348.96 / $15,848.93
| Facility | | $851.14 | $1,348.96 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $2,041.74 / $23,988.33
| Facility | | $630.96 | $2,041.74 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $2,137.96
| Professional | | $1,621.81 | $1,621.81 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |