- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.25 / $167.79 / $167.79
| Facility | | $108.25 | $167.79 | $167.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.25 / $167.79 / $202.35
| Professional | | $108.25 | $167.79 | $202.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.00 / $378.00 / $888.30
| Professional | | $378.00 | $378.00 | $888.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.28 / $191.28 / $191.28
| Professional | | $191.28 | $191.28 | $191.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $367.69 / $5,062.89 / $5,062.89
| Facility | | $367.69 | $5,062.89 | $5,062.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.00 / $1,274.00 / $1,820.10
| Professional | | $1,274.00 | $1,274.00 | $1,820.10 |