- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,237.68 / $1,423.55 / $1,485.22
| Facility | | $1,237.68 | $1,423.55 | $1,485.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.32 / $713.50 / $1,423.56
| Professional | | $30.32 | $713.50 | $1,423.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.52 / $240.52 / $240.52
| Professional | | $240.52 | $240.52 | $240.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.68 / $437.68 / $1,086.80
| Professional | | $437.68 | $437.68 | $1,086.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.68 / $437.68 / $437.68
| Professional | | $437.68 | $437.68 | $437.68 |