- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $824.25 / $824.25 / $989.10
| Facility | | $824.25 | $824.25 | $989.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.61 / $824.25 / $824.25
| Professional | | $118.61 | $824.25 | $824.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.01 / $8.01 / $8.01
| Professional | | $8.01 | $8.01 | $8.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.23 / $14.23 / $14.23
| Professional | | $14.23 | $14.23 | $14.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $3,000.00 / $3,750.00
| Professional | | $2,500.00 | $3,000.00 | $3,750.00 |