- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $68.31 / $68.31 / $83.54
| Facility | | $68.31 | $68.31 | $83.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $723.51 / $1,443.22 / $2,605.42
| Facility | | $723.51 | $1,443.22 | $2,605.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.96 / $967.96 / $967.96
| Professional | | $967.96 | $967.96 | $967.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $68.31 / $239.64 / $515.27
| Facility | | $68.31 | $239.64 | $515.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.69 / $239.64 / $353.53
| Professional | | $235.69 | $239.64 | $353.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $50.00
| Professional | | $30.00 | $30.00 | $50.00 |