- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $428.75 / $1,277.00 / $3,109.00
| Facility | | $428.75 | $1,277.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.75 / $455.81 / $716.70
| Professional | | $428.75 | $455.81 | $716.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.48 / $426.81 / $426.81
| Professional | | $322.48 | $426.81 | $426.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.28 / $635.12 / $818.62
| Professional | | $432.28 | $635.12 | $818.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,056.00 / $2,558.00
| Facility | | $375.00 | $1,056.00 | $2,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.65 / $597.30 / $760.21
| Professional | | $330.65 | $597.30 | $760.21 |