- 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
- $275.42 / $1,047.13 / $1,230.27
| Professional | | $275.42 | $1,047.13 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $426.58 / $707.95
| Facility | | $346.74 | $426.58 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $60.26
| Professional | | $30.20 | $44.67 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $144.54 / $162.18
| Professional | | $123.03 | $144.54 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $120.23 / $125.89
| Professional | | $120.23 | $120.23 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $1,047.13 / $1,258.93
| Professional | | $144.54 | $1,047.13 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $134.90 / $1,000.00
| Professional | | $125.89 | $134.90 | $1,000.00 |