- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.76 / $584.92 / $1,600.00
| Facility | | $145.76 | $584.92 | $1,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.76 / $302.33 / $797.65
| Professional | | $145.76 | $302.33 | $797.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.94 / $168.86 / $237.21
| Facility | | $146.94 | $168.86 | $237.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.54 / $163.54 / $163.54
| Professional | | $163.54 | $163.54 | $163.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.63 / $235.63 / $235.63
| Facility | | $235.63 | $235.63 | $235.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.54 / $545.77 / $1,556.77
| Professional | | $163.54 | $545.77 | $1,556.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.68 / $786.86 / $1,404.42
| Professional | | $255.68 | $786.86 | $1,404.42 |