- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $836.44 / $836.44 / $836.44
| Facility | | $836.44 | $836.44 | $836.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.44 / $836.44 / $836.44
| Professional | | $836.44 | $836.44 | $836.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.00 / $841.00 / $1,072.74
| Professional | | $841.00 | $841.00 | $1,072.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.37 / $807.37 / $807.37
| Professional | | $807.37 | $807.37 | $807.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.02 / $1,020.02 / $3,115.07
| Professional | | $1,020.02 | $1,020.02 | $3,115.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.91 / $782.89 / $1,338.10
| Professional | | $521.91 | $782.89 | $1,338.10 |