- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $162.18
| Facility | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $162.18 / $162.18
| Professional | | $120.23 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,498.45 / $21,379.62 / $21,379.62
| Professional | | $19,498.45 | $21,379.62 | $21,379.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.49 / $257.04 / $436.52
| Facility | | $117.49 | $257.04 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $54.95 / $56.23
| Professional | | $54.95 | $54.95 | $56.23 |