- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.20 / $181.97 / $524.81
| Facility | | $91.20 | $181.97 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $91.20 / $93.33
| Professional | | $91.20 | $91.20 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,479.11
| Facility | | $1,479.11 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $263.03 / $323.59
| Professional | | $223.87 | $263.03 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.20 / $100.00 / $204.17
| Facility | | $91.20 | $100.00 | $204.17 |