- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,086.28 / $1,086.28 / $1,086.28
| Facility | | $1,086.28 | $1,086.28 | $1,086.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.07 / $989.03 / $1,086.28
| Professional | | $828.07 | $989.03 | $1,086.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.99 / $1,156.08 / $1,523.52
| Professional | | $860.99 | $1,156.08 | $1,523.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $1,345.22 / $1,470.39
| Professional | | $30.00 | $1,345.22 | $1,470.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,152.96 / $1,278.08 / $1,278.08
| Facility | | $1,152.96 | $1,278.08 | $1,278.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.77 / $1,308.77 / $1,308.77
| Professional | | $1,308.77 | $1,308.77 | $1,308.77 |