- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.76 / $421.23 / $421.23
| Facility | | $271.76 | $421.23 | $421.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.76 / $417.85 / $452.94
| Professional | | $271.76 | $417.85 | $452.94 |
- 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
- $1,471.74 / $3,202.14 / $3,202.14
| Facility | | $1,471.74 | $3,202.14 | $3,202.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,202.14 / $3,763.97 / $3,867.10
| Professional | | $3,202.14 | $3,763.97 | $3,867.10 |