- 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
- $997.34 / $2,628.83 / $2,628.83
| Facility | | $997.34 | $2,628.83 | $2,628.83 |
- 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
- $305.14 / $557.97 / $1,369.90
| Professional | | $305.14 | $557.97 | $1,369.90 |