- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,398.83 / $2,818.38
| Facility | | $1,737.80 | $2,398.83 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,398.83
| Professional | | $1,737.80 | $1,737.80 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $186.21
| Facility | | $186.21 | $186.21 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,862.09 / $1,862.09
| Professional | | $1,348.96 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.30 / $72.44 / $1,071.52
| Facility | | $12.30 | $72.44 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $2,290.87 / $2,818.38
| Professional | | $776.25 | $2,290.87 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $39.81 / $60.26
| Professional | | $34.67 | $39.81 | $60.26 |