- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,133.79 / $2,925.36 / $3,063.02
| Facility | | $2,133.79 | $2,925.36 | $3,063.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,133.79 / $2,425.44 / $3,063.02
| Professional | | $2,133.79 | $2,425.44 | $3,063.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.62 / $812.62 / $893.88
| Facility | | $812.62 | $812.62 | $893.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.37 / $430.37 / $430.37
| Professional | | $430.37 | $430.37 | $430.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,095.19 / $3,360.51 / $3,360.51
| Facility | | $2,095.19 | $3,360.51 | $3,360.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $1,472.88 / $1,472.88
| Professional | | $192.51 | $1,472.88 | $1,472.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.80 / $390.75 / $2,689.07
| Professional | | $108.80 | $390.75 | $2,689.07 |