- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.65 / $1,550.00 / $1,925.00
| Facility | | $225.65 | $1,550.00 | $1,925.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.46 / $225.65 / $225.65
| Professional | | $203.46 | $225.65 | $225.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $488.18 / $1,286.74 / $1,286.74
| Facility | | $488.18 | $1,286.74 | $1,286.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.69 / $248.58 / $465.00
| Professional | | $207.69 | $248.58 | $465.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.40 / $270.54 / $654.92
| Professional | | $139.40 | $270.54 | $654.92 |