- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $1,527.00 / $3,206.00
| Facility | | $318.75 | $1,527.00 | $3,206.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $475.00
| Professional | | $318.75 | $318.75 | $475.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $435.56 / $521.19 / $658.93
| Facility | | $435.56 | $521.19 | $658.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.83 / $545.16 / $1,090.44
| Facility | | $376.83 | $545.16 | $1,090.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.00 / $540.00 / $915.00
| Professional | | $525.00 | $540.00 | $915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $345.40 / $345.40
| Professional | | $100.00 | $345.40 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |