- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $798.38 / $1,932.07 / $1,932.07
| Facility | | $798.38 | $1,932.07 | $1,932.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.00 / $798.38 / $798.38
| Professional | | $85.00 | $798.38 | $798.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $484.75 / $484.75 / $644.72
| Professional | | $484.75 | $484.75 | $644.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.51 / $291.51 / $610.54
| Professional | | $291.51 | $291.51 | $610.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.40 / $440.40 / $440.40
| Professional | | $440.40 | $440.40 | $440.40 |