- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $501.19 / $1,000.00
| Professional | | $354.81 | $501.19 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $1,096.48
| Facility | | $851.14 | $851.14 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $645.65 / $1,584.89
| Professional | | $549.54 | $645.65 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $575.44 / $851.14
| Professional | | $380.19 | $575.44 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $588.84 / $724.44
| Professional | | $436.52 | $588.84 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $549.54 / $1,023.29
| Professional | | $467.74 | $549.54 | $1,023.29 |