- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.08 / $287.08 / $287.08
| Facility | | $287.08 | $287.08 | $287.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.71 / $287.08 / $1,040.33
| Professional | | $248.71 | $287.08 | $1,040.33 |
- 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
- $504.00 / $668.89 / $902.22
| Facility | | $504.00 | $668.89 | $902.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.93 / $699.93 / $699.93
| Professional | | $699.93 | $699.93 | $699.93 |