- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,579.48 / $1,579.48 / $1,579.48
| Facility | | $1,579.48 | $1,579.48 | $1,579.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.26 / $1,159.41 / $1,579.48
| Professional | | $483.26 | $1,159.41 | $1,579.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,477.50 / $1,477.50 / $1,477.50
| Professional | | $1,477.50 | $1,477.50 | $1,477.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.11 / $109.54 / $2,559.38
| Professional | | $93.11 | $109.54 | $2,559.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.66 / $1,159.41 / $1,579.48
| Facility | | $132.66 | $1,159.41 | $1,579.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.91 / $101.07 / $831.11
| Professional | | $49.91 | $101.07 | $831.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.72 / $101.07 / $831.11
| Professional | | $58.72 | $101.07 | $831.11 |