- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $603.50 / $603.50 / $603.50
| Facility | | $603.50 | $603.50 | $603.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.04 / $603.50 / $1,771.57
| Professional | | $585.04 | $603.50 | $1,771.57 |
- 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
- $907.10 / $1,131.08 / $1,623.83
| Facility | | $907.10 | $1,131.08 | $1,623.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.77 / $683.77 / $683.77
| Professional | | $683.77 | $683.77 | $683.77 |