- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.40 / $193.40 / $232.08
| Facility | | $193.40 | $193.40 | $232.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.67 / $193.40 / $221.71
| Professional | | $173.67 | $193.40 | $221.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.38 / $112.60 / $112.60
| Professional | | $4.38 | $112.60 | $112.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.41 / $293.41 / $293.41
| Facility | | $293.41 | $293.41 | $293.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.38 / $216.38 / $216.38
| Professional | | $216.38 | $216.38 | $216.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.57 / $254.57 / $254.57
| Professional | | $254.57 | $254.57 | $254.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,750.00 / $3,500.00
| Professional | | $2,500.00 | $2,750.00 | $3,500.00 |