- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $360.00 / $540.84 / $540.84
| Facility | | $360.00 | $540.84 | $540.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $32.50 / $492.00
| Professional | | $30.00 | $32.50 | $492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.18 / $407.40 / $539.40
| Professional | | $243.18 | $407.40 | $539.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $69.00 / $99.00
| Professional | | $50.00 | $69.00 | $99.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.59 / $139.52 / $179.18
| Professional | | $118.59 | $139.52 | $179.18 |