- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Facility | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $575.44 / $1,148.15
| Professional | | $275.42 | $575.44 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,000.00 / $1,000.00
| Professional | | $851.14 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $794.33 / $2,454.71
| Professional | | $288.40 | $794.33 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $933.25 / $1,819.70
| Professional | | $724.44 | $933.25 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $724.44 / $1,479.11
| Professional | | $288.40 | $724.44 | $1,479.11 |