- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.00 / $70.00 / $70.00
| Facility | | $70.00 | $70.00 | $70.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.00 / $70.00 / $132.03
| Professional | | $70.00 | $70.00 | $132.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $343.60 / $383.71 / $1,822.80
| Facility | | $343.60 | $383.71 | $1,822.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.97 / $372.20 / $383.71
| Professional | | $306.97 | $372.20 | $383.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.36 / $83.59 / $118.30
| Facility | | $52.36 | $83.59 | $118.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.38 / $259.38 / $259.38
| Professional | | $259.38 | $259.38 | $259.38 |