- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $478.63 / $1,548.82
| Professional | | $263.03 | $478.63 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $588.84 / $1,548.82
| Professional | | $501.19 | $588.84 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $588.84 / $1,548.82
| Professional | | $371.54 | $588.84 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $707.95 / $707.95
| Professional | | $457.09 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $501.19 / $1,000.00
| Professional | | $302.00 | $501.19 | $1,000.00 |