- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $314.60 / $1,268.00 / $2,250.00
| Facility | | $314.60 | $1,268.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.26 / $314.60 / $390.26
| Professional | | $176.26 | $314.60 | $390.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.68 / $273.54 / $322.77
| Professional | | $199.68 | $273.54 | $322.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.00 / $283.39 / $652.52
| Professional | | $186.00 | $283.39 | $652.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.00 / $1,754.00 / $5,201.00
| Facility | | $650.00 | $1,754.00 | $5,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.08 / $193.44 / $293.54
| Professional | | $145.08 | $193.44 | $293.54 |