- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $537.03 / $537.03
| Facility | | $537.03 | $537.03 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $933.25 / $1,096.48
| Professional | | $537.03 | $933.25 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,348.96
| Professional | | $1,174.90 | $1,174.90 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $93.33 / $112.20
| Professional | | $93.33 | $93.33 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $100.00 / $169.82
| Professional | | $64.57 | $100.00 | $169.82 |