- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $710.00 / $1,502.00 / $2,575.00
| Facility | | $710.00 | $1,502.00 | $2,575.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.00 / $1,230.00 / $1,387.00
| Professional | | $650.00 | $1,230.00 | $1,387.00 |
- 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 / $21.25 / $50.00
| Professional | | $17.00 | $21.25 | $50.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.00 / $3,066.00 / $8,411.00
| Facility | | $860.00 | $3,066.00 | $8,411.00 |