- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.93 / $1,268.00 / $2,250.00
| Facility | | $152.93 | $1,268.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.93 / $215.20 / $291.33
| Professional | | $152.93 | $215.20 | $291.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $591.44 / $717.74 / $965.59
| Facility | | $591.44 | $717.74 | $965.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,124.00 / $3,384.00 / $5,251.00
| Facility | | $1,124.00 | $3,384.00 | $5,251.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.13 / $263.48 / $379.20
| Professional | | $208.13 | $263.48 | $379.20 |