- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.22 / $318.22 / $318.22
| Facility | | $318.22 | $318.22 | $318.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.22 / $318.22 / $5,707.27
| Professional | | $318.22 | $318.22 | $5,707.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.45 / $80.80 / $162.69
| Professional | | $42.45 | $80.80 | $162.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.84 / $673.84 / $673.84
| Professional | | $673.84 | $673.84 | $673.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $350.00 / $493.00
| Professional | | $200.00 | $350.00 | $493.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,462.34 / $1,462.34 / $1,462.34
| Facility | | $1,462.34 | $1,462.34 | $1,462.34 |