- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $221.37 / $221.37 / $221.37
| Facility | | $221.37 | $221.37 | $221.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.37 / $221.37 / $221.37
| Professional | | $221.37 | $221.37 | $221.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $60.00
| Professional | | $45.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,161.82 / $2,730.63 / $3,923.50
| Facility | | $2,161.82 | $2,730.63 | $3,923.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.51 / $309.54 / $343.93
| Professional | | $275.51 | $309.54 | $343.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.38 / $245.41 / $489.60
| Professional | | $196.38 | $245.41 | $489.60 |