- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $430.84 / $437.57 / $2,430.00
| Facility | | $430.84 | $437.57 | $2,430.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $404.43 / $646.26 / $687.34
| Professional | | $404.43 | $646.26 | $687.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $595.75 / $595.75 / $595.75
| Professional | | $595.75 | $595.75 | $595.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $502.54 / $502.54 / $502.54
| Facility | | $502.54 | $502.54 | $502.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.16 / $427.16 / $502.54
| Professional | | $427.16 | $427.16 | $502.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.65 / $383.54 / $540.07
| Professional | | $233.65 | $383.54 | $540.07 |