- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $415.64 / $415.64 / $519.54
| Facility | | $415.64 | $415.64 | $519.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.00 / $519.54 / $1,500.00
| Professional | | $360.00 | $519.54 | $1,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.00 / $117.71 / $158.36
| Facility | | $97.00 | $117.71 | $158.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.68 / $243.68 / $311.54
| Professional | | $243.68 | $243.68 | $311.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.76 / $665.68 / $1,680.75
| Facility | | $39.76 | $665.68 | $1,680.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.45 / $109.45 / $136.81
| Professional | | $109.45 | $109.45 | $136.81 |