- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,888.83 / $2,589.53 / $2,711.39
| Facility | | $1,888.83 | $2,589.53 | $2,711.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,888.83 / $2,226.61 / $2,711.39
| Professional | | $1,888.83 | $2,226.61 | $2,711.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $639.51 / $639.51 / $703.47
| Facility | | $639.51 | $639.51 | $703.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.89 / $359.89 / $359.89
| Professional | | $359.89 | $359.89 | $359.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,095.19 / $3,685.49 / $3,685.49
| Facility | | $2,095.19 | $3,685.49 | $3,685.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $3,132.67 / $3,685.49
| Professional | | $192.51 | $3,132.67 | $3,685.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.97 / $313.07 / $2,599.80
| Professional | | $102.97 | $313.07 | $2,599.80 |