- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $714.48 / $714.48 / $714.48
| Facility | | $714.48 | $714.48 | $714.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.46 / $379.06 / $714.48
| Professional | | $3.46 | $379.06 | $714.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,355.25 / $1,807.00 / $2,032.15
| Professional | | $1,355.25 | $1,807.00 | $2,032.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.98 / $217.98 / $217.98
| Professional | | $217.98 | $217.98 | $217.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Professional | | $50.00 | $50.00 | $50.00 |