- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.08 / $1,052.08 / $2,159.84
| Facility | | $1,052.08 | $1,052.08 | $2,159.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.10 / $1,052.08 / $2,159.84
| Professional | | $687.10 | $1,052.08 | $2,159.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.71 / $456.71 / $500.00
| Professional | | $456.71 | $456.71 | $500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.00 / $159.00 / $1,000.81
| Professional | | $159.00 | $159.00 | $1,000.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $400.00 / $493.00
| Professional | | $200.00 | $400.00 | $493.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.53 / $507.53 / $507.53
| Facility | | $507.53 | $507.53 | $507.53 |