- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.76 / $246.91 / $254.32
| Facility | | $205.76 | $246.91 | $254.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.27 / $186.27 / $205.76
| Professional | | $186.27 | $186.27 | $205.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.00 / $70.00 / $70.00
| Professional | | $70.00 | $70.00 | $70.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.36 / $191.36 / $191.36
| Professional | | $191.36 | $191.36 | $191.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.83 / $444.28 / $873.36
| Professional | | $359.83 | $444.28 | $873.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.18 / $302.47 / $683.29
| Professional | | $271.18 | $302.47 | $683.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,750.00 / $3,500.00
| Professional | | $2,500.00 | $2,750.00 | $3,500.00 |