- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $285.20 / $285.20 / $1,932.22
| Facility | | $285.20 | $285.20 | $1,932.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.20 / $285.20 / $285.20
| Professional | | $285.20 | $285.20 | $285.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.43 / $427.80 / $562.25
| Professional | | $407.43 | $427.80 | $562.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $740.46 / $1,003.71 / $2,323.09
| Facility | | $740.46 | $1,003.71 | $2,323.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.80 / $407.43 / $488.92
| Facility | | $317.80 | $407.43 | $488.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.12 / $224.09 / $371.01
| Professional | | $171.12 | $224.09 | $371.01 |