- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.09 / $977.09 / $977.09
| Facility | | $977.09 | $977.09 | $977.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.19 / $1,052.08 / $2,159.84
| Professional | | $719.19 | $1,052.08 | $2,159.84 |
- 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
- $756.56 / $1,031.20 / $1,502.75
| Facility | | $756.56 | $1,031.20 | $1,502.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $711.04 / $711.04 / $711.04
| Professional | | $711.04 | $711.04 | $711.04 |