- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $280.22 / $1,125.00 / $1,836.00
| Facility | | $280.22 | $1,125.00 | $1,836.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.00 / $425.00 / $475.00
| Professional | | $425.00 | $425.00 | $475.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.01 / $8.01 / $8.01
| Professional | | $8.01 | $8.01 | $8.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.85 / $759.65 / $935.11
| Facility | | $239.85 | $759.65 | $935.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $425.00 / $488.75 / $858.50
| Facility | | $425.00 | $488.75 | $858.50 |