- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $936.88 / $936.88 / $936.88
| Facility | | $936.88 | $936.88 | $936.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.75 / $823.19 / $840.94
| Professional | | $96.75 | $823.19 | $840.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.50 / $2,326.50 / $2,436.12
| Professional | | $2,326.50 | $2,326.50 | $2,436.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.78 / $126.78 / $126.78
| Professional | | $126.78 | $126.78 | $126.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.01 / $936.88 / $959.98
| Professional | | $510.01 | $936.88 | $959.98 |