- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.78 / $1,268.00 / $2,250.00
| Facility | | $153.78 | $1,268.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.86 / $153.78 / $173.19
| Professional | | $142.86 | $153.78 | $173.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.53 / $607.41 / $817.17
| Facility | | $500.53 | $607.41 | $817.17 |
- 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
- $238.30 / $285.95 / $381.28
| Professional | | $238.30 | $285.95 | $381.28 |