- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $409.21 / $798.83 / $1,274.49
| Facility | | $409.21 | $798.83 | $1,274.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $722.85 / $1,512.90 / $2,020.54
| Facility | | $722.85 | $1,512.90 | $2,020.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.55 / $307.55 / $307.55
| Professional | | $307.55 | $307.55 | $307.55 |
- 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 |