- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $586.25 / $1,246.70 / $1,276.34
| Facility | | $586.25 | $1,246.70 | $1,276.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.25 / $855.25 / $916.34
| Professional | | $855.25 | $855.25 | $916.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $971.78 / $2,066.92 / $3,664.53
| Facility | | $971.78 | $2,066.92 | $3,664.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $855.25 / $940.78 / $1,453.93
| Facility | | $855.25 | $940.78 | $1,453.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |