- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.85 / $1,616.15 / $2,798.71
| Facility | | $707.85 | $1,616.15 | $2,798.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.97 / $507.25 / $1,110.84
| Facility | | $293.97 | $507.25 | $1,110.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.74 / $97.74 / $97.74
| Professional | | $97.74 | $97.74 | $97.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.92 / $47.92 / $47.92
| Professional | | $47.92 | $47.92 | $47.92 |