- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,605.69 / $1,605.69 / $1,605.69
| Facility | | $1,605.69 | $1,605.69 | $1,605.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,137.54 / $1,605.69 / $2,644.65
| Professional | | $1,137.54 | $1,605.69 | $2,644.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.71 / $1,503.13 / $1,503.13
| Professional | | $163.71 | $1,503.13 | $1,503.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.18 / $1,350.95 / $2,644.65
| Facility | | $243.18 | $1,350.95 | $2,644.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.44 / $209.65 / $1,572.43
| Professional | | $138.44 | $209.65 | $1,572.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.67 / $1,232.08 / $3,098.29
| Professional | | $1,108.67 | $1,232.08 | $3,098.29 |