- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.71 / $242.71 / $242.71
| Facility | | $242.71 | $242.71 | $242.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.71 / $242.71 / $311.20
| Professional | | $242.71 | $242.71 | $311.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $428.50 / $632.31 / $975.72
| Facility | | $428.50 | $632.31 | $975.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.22 / $204.20 / $500.00
| Professional | | $141.22 | $204.20 | $500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.39 / $263.39 / $263.39
| Facility | | $263.39 | $263.39 | $263.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.04 / $116.04 / $116.04
| Professional | | $116.04 | $116.04 | $116.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.70 / $57.70 / $57.70
| Professional | | $57.70 | $57.70 | $57.70 |