- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.86 / $47.86 / $47.86
| Facility | | $47.86 | $47.86 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $1,995.26
| Professional | | $30.20 | $44.67 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $912.01 / $1,230.27
| Professional | | $602.56 | $912.01 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Professional | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $54.95 / $87.10
| Professional | | $50.12 | $54.95 | $87.10 |