- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,573.38 / $1,573.38 / $1,573.38
| Facility | | $1,573.38 | $1,573.38 | $1,573.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,573.38 / $2,354.80 / $4,358.13
| Professional | | $1,573.38 | $2,354.80 | $4,358.13 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $243.40 / $2,449.92 / $4,358.13
| Facility | | $243.40 | $2,449.92 | $4,358.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.26 / $551.63 / $4,071.02
| Professional | | $228.26 | $551.63 | $4,071.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.19 / $358.54 / $3,286.64
| Professional | | $163.19 | $358.54 | $3,286.64 |