- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $876.05 / $876.05 / $876.05
| Facility | | $876.05 | $876.05 | $876.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.04 / $540.96 / $876.05
| Professional | | $356.04 | $540.96 | $876.05 |
- 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
- $544.36 / $980.47 / $1,428.83
| Facility | | $544.36 | $980.47 | $1,428.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $747.40 / $747.40 / $747.40
| Professional | | $747.40 | $747.40 | $747.40 |