- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.28 / $146.58 / $161.36
| Professional | | $137.28 | $146.58 | $161.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.04 / $14.04 / $14.04
| Facility | | $14.04 | $14.04 | $14.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $424.10 / $728.08 / $2,047.03
| Facility | | $424.10 | $728.08 | $2,047.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $500.00
| Facility | | $500.00 | $500.00 | $500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.38 / $851.38 / $893.94
| Professional | | $851.38 | $851.38 | $893.94 |