- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $256.86 / $256.86 / $1,178.00
| Facility | | $256.86 | $256.86 | $1,178.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.99 / $256.86 / $388.87
| Professional | | $243.99 | $256.86 | $388.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.00 / $571.54 / $916.51
| Professional | | $497.00 | $571.54 | $916.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,970.10 / $12,970.10 / $16,024.22
| Facility | | $12,970.10 | $12,970.10 | $16,024.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $50.00 / $60.00
| Professional | | $40.00 | $50.00 | $60.00 |