- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.92 / $182.05 / $393.23
| Facility | | $165.92 | $182.05 | $393.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.00 / $490.86 / $652.00
| Professional | | $25.00 | $490.86 | $652.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.08 / $508.08 / $508.08
| Facility | | $508.08 | $508.08 | $508.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.40 / $517.50 / $3,335.23
| Professional | | $95.40 | $517.50 | $3,335.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $65.00 / $85.00
| Professional | | $50.00 | $65.00 | $85.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,335.23 / $3,335.23 / $3,335.23
| Professional | | $3,335.23 | $3,335.23 | $3,335.23 |