- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $475.00 / $936.00 / $1,831.00
| Facility | | $475.00 | $936.00 | $1,831.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.96 / $517.82 / $657.63
| Professional | | $396.96 | $517.82 | $657.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.87 / $455.87 / $455.87
| Professional | | $455.87 | $455.87 | $455.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $38.25
| Professional | | $17.00 | $20.00 | $38.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $690.00 / $1,236.00 / $5,253.00
| Facility | | $690.00 | $1,236.00 | $5,253.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.33 / $663.24 / $1,005.24
| Professional | | $520.33 | $663.24 | $1,005.24 |