- 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 / $425.63
| Professional | | $318.75 | $318.75 | $425.63 |
- 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
- $264.67 / $264.67 / $264.67
| Professional | | $264.67 | $264.67 | $264.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $258.30 / $357.13 / $1,047.49
| Facility | | $258.30 | $357.13 | $1,047.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.31 / $1,079.31 / $1,079.31
| Professional | | $1,079.31 | $1,079.31 | $1,079.31 |