- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $485.00 / $960.00 / $2,250.00
| Facility | | $485.00 | $960.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.55 / $131.55 / $749.38
| Professional | | $131.55 | $131.55 | $749.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $612.85 / $743.72 / $1,000.54
| Facility | | $612.85 | $743.72 | $1,000.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.00 / $850.00 / $1,349.00
| Facility | | $241.00 | $850.00 | $1,349.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.75 / $43.34 / $57.47
| Professional | | $33.75 | $43.34 | $57.47 |