- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.81 / $203.17 / $1,400.00
| Facility | | $122.81 | $203.17 | $1,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.81 / $191.79 / $234.00
| Professional | | $122.81 | $191.79 | $234.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $220.54 / $220.54 / $220.54
| Facility | | $220.54 | $220.54 | $220.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.81 / $216.03 / $497.45
| Professional | | $123.81 | $216.03 | $497.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.22 / $241.04 / $376.02
| Professional | | $162.22 | $241.04 | $376.02 |