- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.15 / $194.07 / $1,200.00
| Facility | | $118.15 | $194.07 | $1,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.34 / $222.69 / $432.67
| Professional | | $164.34 | $222.69 | $432.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.05 / $240.05 / $240.05
| Facility | | $240.05 | $240.05 | $240.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.57 / $275.57 / $1,443.73
| Professional | | $275.57 | $275.57 | $1,443.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.84 / $555.80 / $829.58
| Professional | | $362.84 | $555.80 | $829.58 |