- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $478.63
| Facility | | $478.63 | $478.63 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $794.33 / $1,000.00
| Professional | | $478.63 | $794.33 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $1,288.25 / $1,288.25
| Professional | | $128.82 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $93.33 / $109.65
| Professional | | $93.33 | $93.33 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $95.50 / $154.88
| Professional | | $79.43 | $95.50 | $154.88 |