- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.24 / $228.24 / $228.24
| Facility | | $228.24 | $228.24 | $228.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.98 / $226.13 / $266.33
| Professional | | $206.98 | $226.13 | $266.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.04 / $258.23 / $258.23
| Professional | | $102.04 | $258.23 | $258.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.23 / $258.23 / $258.23
| Professional | | $258.23 | $258.23 | $258.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.81 / $65.81 / $65.81
| Professional | | $65.81 | $65.81 | $65.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.00 / $237.27 / $294.29
| Facility | | $202.00 | $237.27 | $294.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,000.00 / $3,000.00 / $3,000.00
| Professional | | $3,000.00 | $3,000.00 | $3,000.00 |