- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.35 / $501.35 / $1,061.57
| Facility | | $501.35 | $501.35 | $1,061.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.00 / $450.67 / $850.05
| Professional | | $360.00 | $450.67 | $850.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.40 / $426.12 / $429.30
| Professional | | $360.40 | $426.12 | $429.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.45 / $110.54 / $139.00
| Professional | | $109.45 | $110.54 | $139.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.35 / $501.35 / $852.30
| Facility | | $501.35 | $501.35 | $852.30 |