- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $785.65 / $785.65 / $982.06
| Facility | | $785.65 | $785.65 | $982.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.65 / $1,046.84 / $1,151.54
| Professional | | $785.65 | $1,046.84 | $1,151.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $99.01 / $99.01 / $99.01
| Facility | | $99.01 | $99.01 | $99.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $85.00 / $1,500.00
| Professional | | $60.00 | $85.00 | $1,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $99.01 / $99.01 / $758.75
| Facility | | $99.01 | $99.01 | $758.75 |