- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $233.56 / $233.56 / $233.56
| Facility | | $233.56 | $233.56 | $233.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.56 / $233.56 / $1,198.68
| Professional | | $233.56 | $233.56 | $1,198.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $233.56 / $245.24 / $494.20
| Facility | | $233.56 | $245.24 | $494.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,219.31 / $2,536.35 / $2,536.35
| Professional | | $2,219.31 | $2,536.35 | $2,536.35 |