- 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 / $291.25 / $311.20
| Professional | | $242.71 | $291.25 | $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
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $417.79 / $1,092.10 / $1,591.52
| Facility | | $417.79 | $1,092.10 | $1,591.52 |