- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $549.54 / $1,047.13
| Facility | | $407.38 | $549.54 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $549.54 / $1,737.80
| Professional | | $407.38 | $549.54 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,122.02 / $1,318.26
| Professional | | $851.14 | $1,122.02 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $851.14
| Professional | | $660.69 | $660.69 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $691.83 / $2,754.23
| Facility | | $407.38 | $691.83 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $407.38 / $1,000.00
| Professional | | $288.40 | $407.38 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $588.84 / $977.24
| Professional | | $288.40 | $588.84 | $977.24 |