- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $209.72 / $964.50
| Professional | | $100.00 | $209.72 | $964.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.06 / $251.06 / $251.06
| Facility | | $251.06 | $251.06 | $251.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.32 / $337.32 / $337.32
| Professional | | $337.32 | $337.32 | $337.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.06 / $251.06 / $251.06
| Facility | | $251.06 | $251.06 | $251.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.50 / $97.50 / $337.32
| Professional | | $97.50 | $97.50 | $337.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.52 / $150.00 / $675.00
| Professional | | $65.52 | $150.00 | $675.00 |