- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $9,120.11 / $16,595.87
| Facility | | $1,862.09 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Professional | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $371.54
| Professional | | $346.74 | $346.74 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,290.87 / $3,981.07
| Facility | | $1,862.09 | $2,290.87 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $54.95
| Professional | | $30.20 | $30.20 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $6,760.83 / $9,120.11
| Facility | | $2,454.71 | $6,760.83 | $9,120.11 |