- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $597.13 / $597.13 / $597.13
| Facility | | $597.13 | $597.13 | $597.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.89 / $631.35 / $1,182.51
| Professional | | $520.89 | $631.35 | $1,182.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.11 / $93.11 / $121.19
| Professional | | $93.11 | $93.11 | $121.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.56 / $1,044.56 / $1,044.56
| Professional | | $1,044.56 | $1,044.56 | $1,044.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.51 / $84.90 / $563.25
| Professional | | $70.51 | $84.90 | $563.25 |