- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.00 / $70.00 / $70.00
| Professional | | $70.00 | $70.00 | $70.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.13 / $313.23 / $387.66
| Professional | | $310.13 | $313.23 | $387.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $200.00 / $363.58
| Professional | | $150.00 | $200.00 | $363.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.00 / $84.00 / $146.72
| Facility | | $70.00 | $84.00 | $146.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,321.08 / $6,321.08 / $6,321.08
| Facility | | $6,321.08 | $6,321.08 | $6,321.08 |