- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.66 / $117.66 / $117.66
| Facility | | $117.66 | $117.66 | $117.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.62 / $86.21 / $117.66
| Professional | | $59.62 | $86.21 | $117.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.24 / $785.24 / $785.24
| Professional | | $785.24 | $785.24 | $785.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $59.62 / $117.66 / $1,165.25
| Facility | | $59.62 | $117.66 | $1,165.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,438.66 / $1,438.66 / $4,904.35
| Professional | | $1,438.66 | $1,438.66 | $4,904.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,438.66 / $1,438.66 / $1,619.50
| Professional | | $1,438.66 | $1,438.66 | $1,619.50 |