- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,229.88 / $3,229.88 / $3,229.88
| Facility | | $3,229.88 | $3,229.88 | $3,229.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.38 / $2,840.07 / $3,480.47
| Professional | | $347.38 | $2,840.07 | $3,480.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.88 / $132.25 / $220.45
| Facility | | $109.88 | $132.25 | $220.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,784.38
| Professional | | $2,784.38 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.95 / $72.79 / $269.64
| Professional | | $50.95 | $72.79 | $269.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.02 / $2,756.54 / $3,062.82
| Professional | | $135.02 | $2,756.54 | $3,062.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,784.38
| Professional | | $2,784.38 | $2,784.38 | $2,784.38 |