- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Professional | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $123.03
| Professional | | $102.33 | $102.33 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $812.83 / $870.96
| Facility | | $758.58 | $812.83 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $123.03 / $162.18
| Professional | | $123.03 | $123.03 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Professional | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $338.84 / $562.34
| Facility | | $281.84 | $338.84 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $416.87 / $630.96
| Professional | | $208.93 | $416.87 | $630.96 |