- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $483.26 / $483.26 / $483.26
| Facility | | $483.26 | $483.26 | $483.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.26 / $483.26 / $1,159.41
| Professional | | $483.26 | $483.26 | $1,159.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.11 / $109.54 / $2,047.50
| Professional | | $93.11 | $109.54 | $2,047.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $82.35 / $1,866.40
| Professional | | $60.00 | $82.35 | $1,866.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.59 / $74.86 / $708.72
| Professional | | $67.59 | $74.86 | $708.72 |