- 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
- $264.14 / $264.14 / $264.14
| Professional | | $264.14 | $264.14 | $264.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $258.30 / $357.13 / $1,360.46
| Facility | | $258.30 | $357.13 | $1,360.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,178.40 / $1,178.40 / $1,178.40
| Professional | | $1,178.40 | $1,178.40 | $1,178.40 |