- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.10 / $271.10 / $1,400.00
| Facility | | $271.10 | $271.10 | $1,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.09 / $271.10 / $311.30
| Professional | | $234.09 | $271.10 | $311.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.38 / $342.36 / $373.02
| Facility | | $306.38 | $342.36 | $373.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.57 / $331.57 / $331.57
| Professional | | $331.57 | $331.57 | $331.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.06 / $330.06 / $330.06
| Facility | | $330.06 | $330.06 | $330.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.22 / $386.83 / $1,496.52
| Professional | | $281.22 | $386.83 | $1,496.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.20 / $346.13 / $485.03
| Professional | | $221.20 | $346.13 | $485.03 |