- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $313.70 / $1,315.64 / $1,822.61
| Facility | | $313.70 | $1,315.64 | $1,822.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.70 / $313.70 / $442.31
| Professional | | $313.70 | $313.70 | $442.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $60.00 / $282.29
| Professional | | $45.00 | $60.00 | $282.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.05 / $442.42 / $465.69
| Professional | | $359.05 | $442.42 | $465.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.05 / $359.05 / $359.05
| Professional | | $359.05 | $359.05 | $359.05 |