- 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
- $1,478.10 / $2,405.11 / $3,808.60
| Professional | | $1,478.10 | $2,405.11 | $3,808.60 |
- 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 / $2,233.94 / $3,808.60
| Facility | | $243.40 | $2,233.94 | $3,808.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.55 / $325.79 / $3,257.90
| Professional | | $182.55 | $325.79 | $3,257.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.24 / $254.65 / $1,909.85
| Professional | | $143.24 | $254.65 | $1,909.85 |