- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,033.58 / $1,510.00 / $2,205.23
| Facility | | $1,033.58 | $1,510.00 | $2,205.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.58 / $1,145.06 / $1,409.05
| Professional | | $1,033.58 | $1,145.06 | $1,409.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.86 / $520.86 / $520.86
| Professional | | $520.86 | $520.86 | $520.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.34 / $13.34 / $13.34
| Professional | | $13.34 | $13.34 | $13.34 |