- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $3,548.13
| Facility | | $309.03 | $309.03 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $575.44
| Professional | | $309.03 | $309.03 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Professional | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $44.67 / $3,019.95
| Professional | | $44.67 | $44.67 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $436.52 / $436.52
| Professional | | $436.52 | $436.52 | $436.52 |