- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.39 / $540.39 / $1,389.56
| Facility | | $540.39 | $540.39 | $1,389.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.39 / $540.39 / $540.39
| Professional | | $540.39 | $540.39 | $540.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.38 / $1,555.54 / $1,745.64
| Professional | | $1,283.38 | $1,555.54 | $1,745.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.12 / $896.00 / $1,126.65
| Professional | | $887.12 | $896.00 | $1,126.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.39 / $918.66 / $3,666.91
| Facility | | $540.39 | $918.66 | $3,666.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.23 / $771.98 / $1,312.37
| Professional | | $324.23 | $771.98 | $1,312.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.23 / $393.71 / $1,119.36
| Professional | | $324.23 | $393.71 | $1,119.36 |