- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.16 / $1,230.16 / $1,230.16
| Facility | | $1,230.16 | $1,230.16 | $1,230.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.00 / $457.81 / $712.63
| Professional | | $264.00 | $457.81 | $712.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,520.59 / $2,157.63 / $4,427.93
| Facility | | $1,520.59 | $2,157.63 | $4,427.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.57 / $836.57 / $2,188.17
| Professional | | $836.57 | $836.57 | $2,188.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.11 / $630.92 / $1,245.39
| Professional | | $389.11 | $630.92 | $1,245.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $423.05 / $732.39 / $1,245.39
| Professional | | $423.05 | $732.39 | $1,245.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $696.36 / $782.21 / $2,273.92
| Professional | | $696.36 | $782.21 | $2,273.92 |