- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.00 / $2,502.00 / $2,733.64
| Facility | | $400.00 | $2,502.00 | $2,733.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.00 / $400.00 / $425.00
| Professional | | $400.00 | $400.00 | $425.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.95 / $1,353.54 / $1,719.73
| Professional | | $1,093.95 | $1,353.54 | $1,719.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $632.14 / $1,796.48 / $1,797.87
| Facility | | $632.14 | $1,796.48 | $1,797.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.35 / $344.35 / $344.35
| Professional | | $344.35 | $344.35 | $344.35 |