- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.22 / $104.22 / $132.36
| Facility | | $104.22 | $104.22 | $132.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.22 / $104.22 / $304.11
| Professional | | $104.22 | $104.22 | $304.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38,249.62 / $38,249.62 / $38,249.62
| Professional | | $38,249.62 | $38,249.62 | $38,249.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $220.16 / $220.16 / $220.16
| Facility | | $220.16 | $220.16 | $220.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.22 / $132.36 / $330.68
| Facility | | $104.22 | $132.36 | $330.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.22 / $104.22 / $304.11
| Professional | | $104.22 | $104.22 | $304.11 |