- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $311.20 / $311.20 / $311.20
| Facility | | $311.20 | $311.20 | $311.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.71 / $292.31 / $311.20
| Professional | | $242.71 | $292.31 | $311.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.04 / $116.04 / $116.04
| Professional | | $116.04 | $116.04 | $116.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $959.15 / $1,207.71 / $2,517.96
| Facility | | $959.15 | $1,207.71 | $2,517.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.00 / $1,200.00 / $1,200.00
| Professional | | $1,020.00 | $1,200.00 | $1,200.00 |