- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $692.82 / $900.00
| Facility | | $318.75 | $692.82 | $900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $425.00
| Professional | | $318.75 | $318.75 | $425.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.00 / $706.00 / $1,000.00
| Facility | | $510.00 | $706.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.51 / $1,135.25 / $1,235.09
| Professional | | $597.51 | $1,135.25 | $1,235.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.94 / $1,231.94 / $1,231.94
| Professional | | $1,231.94 | $1,231.94 | $1,231.94 |