- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.00 / $307.00 / $307.00
| Facility | | $307.00 | $307.00 | $307.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.00 / $525.00 / $525.00
| Facility | | $525.00 | $525.00 | $525.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $50.00
| Professional | | $40.00 | $40.00 | $50.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.50 / $1,463.63 / $3,293.17
| Facility | | $650.50 | $1,463.63 | $3,293.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.09 / $354.09 / $354.09
| Professional | | $354.09 | $354.09 | $354.09 |