- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.46 / $351.46 / $1,700.00
| Facility | | $243.46 | $351.46 | $1,700.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.46 / $328.19 / $391.56
| Professional | | $243.46 | $328.19 | $391.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $431.85 / $431.85 / $431.85
| Facility | | $431.85 | $431.85 | $431.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.02 / $367.11 / $777.19
| Professional | | $243.02 | $367.11 | $777.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.14 / $409.36 / $549.89
| Professional | | $264.14 | $409.36 | $549.89 |