- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.78 / $923.53 / $1,940.60
| Facility | | $507.78 | $923.53 | $1,940.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.78 / $507.78 / $507.78
| Professional | | $507.78 | $507.78 | $507.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,197.46 / $1,197.46 / $1,197.46
| Facility | | $1,197.46 | $1,197.46 | $1,197.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.34 / $489.34 / $489.34
| Professional | | $489.34 | $489.34 | $489.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |