- 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
- $195.35 / $267.60 / $315.77
| Professional | | $195.35 | $267.60 | $315.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.00 / $274.37 / $642.00
| Professional | | $186.00 | $274.37 | $642.00 |
- 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 / $201.72 / $309.50
| Professional | | $145.08 | $201.72 | $309.50 |