- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $1,527.00 / $3,206.00
| Facility | | $318.75 | $1,527.00 | $3,206.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $475.00
| Professional | | $318.75 | $318.75 | $475.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.11 / $259.79 / $328.45
| Facility | | $217.11 | $259.79 | $328.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.45 / $265.91 / $822.00
| Facility | | $184.45 | $265.91 | $822.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $345.40 / $345.40
| Professional | | $100.00 | $345.40 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |