- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $483.31 / $483.31 / $483.31
| Facility | | $483.31 | $483.31 | $483.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.31 / $624.74 / $624.74
| Professional | | $483.31 | $624.74 | $624.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $712.84 / $712.84 / $712.84
| Facility | | $712.84 | $712.84 | $712.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.83 / $759.00 / $2,949.84
| Professional | | $211.83 | $759.00 | $2,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.90 / $493.78 / $864.96
| Professional | | $192.90 | $493.78 | $864.96 |