- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $513.41 / $513.41 / $513.41
| Facility | | $513.41 | $513.41 | $513.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.41 / $798.38 / $798.38
| Professional | | $513.41 | $798.38 | $798.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.51 / $291.51 / $291.51
| Professional | | $291.51 | $291.51 | $291.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $798.38 / $822.33 / $1,021.93
| Facility | | $798.38 | $822.33 | $1,021.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $55.00 / $3,900.00
| Professional | | $30.00 | $55.00 | $3,900.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $938.71 / $1,289.20 / $1,619.68
| Facility | | $938.71 | $1,289.20 | $1,619.68 |