- 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
- $280.16 / $318.75 / $425.00
| Professional | | $280.16 | $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
- $264.67 / $264.67 / $264.67
| Professional | | $264.67 | $264.67 | $264.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.60 / $241.72 / $1,509.07
| Facility | | $174.60 | $241.72 | $1,509.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.35 / $344.35 / $344.35
| Professional | | $344.35 | $344.35 | $344.35 |