- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.00 / $382.49 / $503.61
| Professional | | $371.00 | $382.49 | $503.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.53 / $1,621.49 / $1,919.64
| Facility | | $1,200.53 | $1,621.49 | $1,919.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $471.42 / $554.61 / $767.87
| Professional | | $471.42 | $554.61 | $767.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $397.94 / $397.94 / $491.14
| Facility | | $397.94 | $397.94 | $491.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.50 / $397.94 / $397.94
| Professional | | $290.50 | $397.94 | $397.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.87 / $478.11 / $706.03
| Professional | | $382.87 | $478.11 | $706.03 |