- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,863.22 / $3,409.69 / $3,782.34
| Facility | | $1,863.22 | $3,409.69 | $3,782.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.95 / $3,409.69 / $3,782.34
| Professional | | $1,471.95 | $3,409.69 | $3,782.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,863.22 / $1,863.22 / $1,863.22
| Facility | | $1,863.22 | $1,863.22 | $1,863.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,863.22 / $1,863.22 / $1,863.22
| Professional | | $1,863.22 | $1,863.22 | $1,863.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $30.00 / $50.00
| Professional | | $21.25 | $30.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $1,117.93 / $3,167.47
| Professional | | $782.55 | $1,117.93 | $3,167.47 |