- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $906.42 / $906.42 / $906.42
| Facility | | $906.42 | $906.42 | $906.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $435.35 / $861.86 / $906.42
| Professional | | $435.35 | $861.86 | $906.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.35 / $586.50 / $1,280.85
| Professional | | $172.35 | $586.50 | $1,280.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.26 / $1,105.20 / $1,708.04
| Professional | | $904.26 | $1,105.20 | $1,708.04 |