- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.50 / $492.13 / $492.13
| Facility | | $317.50 | $492.13 | $492.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.20 / $488.28 / $529.16
| Professional | | $312.20 | $488.28 | $529.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $535.00 / $535.00 / $1,257.25
| Professional | | $535.00 | $535.00 | $1,257.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,287.90 / $3,299.61 / $3,299.61
| Facility | | $1,287.90 | $3,299.61 | $3,299.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,663.00 / $3,879.51 / $3,985.81
| Professional | | $3,663.00 | $3,879.51 | $3,985.81 |