- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $84.34 / $96.82 / $289.77
| Facility | | $84.34 | $96.82 | $289.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.44 / $75.44 / $75.44
| Facility | | $75.44 | $75.44 | $75.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,995.49 / $2,995.49 / $3,744.36
| Professional | | $2,995.49 | $2,995.49 | $3,744.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $84.34 / $96.82 / $289.77
| Facility | | $84.34 | $96.82 | $289.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.00 / $14.00 / $14.00
| Professional | | $14.00 | $14.00 | $14.00 |