- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $433.76 / $839.17 / $1,303.09
| Facility | | $433.76 | $839.17 | $1,303.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $609.91 / $972.64 / $1,127.00
| Facility | | $609.91 | $972.64 | $1,127.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.43 / $206.43 / $206.43
| Professional | | $206.43 | $206.43 | $206.43 |
- 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 |