- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $251.19 / $316.23
| Professional | | $173.78 | $251.19 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,238.72 / $2,691.53
| Facility | | $1,995.26 | $2,238.72 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $562.34 / $741.31
| Professional | | $199.53 | $562.34 | $741.31 |
- 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
- $39.81 / $39.81 / $39.81
| Professional | | $39.81 | $39.81 | $39.81 |