- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $519.54 / $519.54 / $519.54
| Facility | | $519.54 | $519.54 | $519.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.00 / $519.54 / $2,356.00
| Professional | | $360.00 | $519.54 | $2,356.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.65 / $179.60 / $350.20
| Facility | | $137.65 | $179.60 | $350.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $532.75 / $1,065.52 / $1,149.64
| Professional | | $532.75 | $1,065.52 | $1,149.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.45 / $172.99 / $216.24
| Professional | | $109.45 | $172.99 | $216.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $519.54 / $987.15 / $1,360.91
| Facility | | $519.54 | $987.15 | $1,360.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.55 / $176.55 / $176.55
| Professional | | $176.55 | $176.55 | $176.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.15 / $265.89 / $273.64
| Facility | | $180.15 | $265.89 | $273.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.15 / $180.15 / $180.15
| Professional | | $180.15 | $180.15 | $180.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.55 / $176.55 / $176.55
| Professional | | $176.55 | $176.55 | $176.55 |