- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.23 / $936.00 / $2,010.00
| Facility | | $104.23 | $936.00 | $2,010.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.23 / $169.58 / $186.53
| Professional | | $104.23 | $169.58 | $186.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $593.75 / $593.75 / $593.75
| Facility | | $593.75 | $593.75 | $593.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $302.00 / $302.00
| Professional | | $302.00 | $302.00 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $42.50 / $50.00
| Professional | | $21.25 | $42.50 | $50.00 |