- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.36 / $1,268.00 / $2,250.00
| Facility | | $562.36 | $1,268.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.33 / $562.36 / $562.36
| Professional | | $322.33 | $562.36 | $562.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.08 / $433.00 / $510.94
| Professional | | $316.08 | $433.00 | $510.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.96 / $488.10 / $1,216.74
| Professional | | $348.96 | $488.10 | $1,216.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $625.00 / $1,768.00 / $3,360.00
| Facility | | $625.00 | $1,768.00 | $3,360.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.33 / $372.88 / $568.19
| Professional | | $266.33 | $372.88 | $568.19 |