- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $485.00 / $960.00 / $2,250.00
| Facility | | $485.00 | $960.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.37 / $241.17 / $306.02
| Professional | | $194.37 | $241.17 | $306.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,273.48 / $1,545.43 / $2,079.10
| Facility | | $1,273.48 | $1,545.43 | $2,079.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $625.00 / $1,738.00 / $3,360.00
| Facility | | $625.00 | $1,738.00 | $3,360.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.22 / $313.62 / $512.20
| Professional | | $235.22 | $313.62 | $512.20 |