- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $900.00 / $2,373.00
| Facility | | $318.75 | $900.00 | $2,373.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $425.00
| Professional | | $318.75 | $318.75 | $425.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.00 / $1,051.00 / $2,769.54
| Facility | | $510.00 | $1,051.00 | $2,769.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.88 / $507.88 / $507.88
| Professional | | $507.88 | $507.88 | $507.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $258.30 / $357.13
| Facility | | $64.00 | $258.30 | $357.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.94 / $1,231.94 / $1,231.94
| Professional | | $1,231.94 | $1,231.94 | $1,231.94 |