- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $483.26 / $1,035.69 / $1,066.59
| Facility | | $483.26 | $1,035.69 | $1,066.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.26 / $1,066.59 / $1,066.59
| Professional | | $483.26 | $1,066.59 | $1,066.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.06 / $1,284.27 / $2,030.00
| Professional | | $1,082.06 | $1,284.27 | $2,030.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.11 / $93.11 / $121.19
| Professional | | $93.11 | $93.11 | $121.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.54 / $176.54 / $493.00
| Professional | | $176.54 | $176.54 | $493.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.62 / $74.86 / $507.42
| Professional | | $58.62 | $74.86 | $507.42 |