- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.37 / $267.17 / $267.17
| Facility | | $172.37 | $267.17 | $267.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.87 / $267.17 / $287.27
| Professional | | $169.87 | $267.17 | $287.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.00 / $578.00 / $1,358.30
| Professional | | $578.00 | $578.00 | $1,358.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $522.26 / $3,728.65 / $3,728.65
| Facility | | $522.26 | $3,728.65 | $3,728.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.54 / $1,819.54 / $2,338.50
| Professional | | $1,819.54 | $1,819.54 | $2,338.50 |