- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $441.26 / $441.26 / $441.26
| Facility | | $441.26 | $441.26 | $441.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.15 / $242.05 / $441.26
| Professional | | $171.15 | $242.05 | $441.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $628.24 / $793.54 / $1,151.65
| Facility | | $628.24 | $793.54 | $1,151.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.93 / $699.93 / $699.93
| Professional | | $699.93 | $699.93 | $699.93 |