- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.72 / $131.72 / $131.72
| Facility | | $131.72 | $131.72 | $131.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.40 / $131.72 / $132.65
| Professional | | $80.40 | $131.72 | $132.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.25 / $43.00 / $43.00
| Professional | | $32.25 | $43.00 | $43.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53,899.46 / $61,249.39 / $61,249.39
| Facility | | $53,899.46 | $61,249.39 | $61,249.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $3,000.00
| Professional | | $45.00 | $45.00 | $3,000.00 |