- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $518.14 / $605.49 / $928.84
| Facility | | $518.14 | $605.49 | $928.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.44 / $247.73 / $648.87
| Professional | | $135.44 | $247.73 | $648.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.00 / $1,386.51 / $1,386.51
| Professional | | $1,204.00 | $1,386.51 | $1,386.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.40 / $70.00
| Professional | | $50.00 | $58.40 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $677.34 / $677.34 / $677.34
| Facility | | $677.34 | $677.34 | $677.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.14 / $1,204.00 / $1,386.51
| Professional | | $346.14 | $1,204.00 | $1,386.51 |