- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $82.86 / $927.00 / $2,250.00
| Facility | | $82.86 | $927.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.22 / $77.51 / $167.27
| Professional | | $56.22 | $77.51 | $167.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.70 / $264.19 / $355.42
| Facility | | $217.70 | $264.19 | $355.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.08 / $750.00 / $1,326.00
| Facility | | $225.08 | $750.00 | $1,326.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.83 / $98.42 / $125.72
| Professional | | $79.83 | $98.42 | $125.72 |