- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $403.89 / $836.47 / $3,070.90
| Facility | | $403.89 | $836.47 | $3,070.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $1,032.19
| Professional | | $836.47 | $836.47 | $1,032.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $360.74 / $360.74
| Professional | | $360.74 | $360.74 | $360.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $50.00
| Professional | | $40.00 | $40.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.54 / $343.54 / $343.54
| Professional | | $343.54 | $343.54 | $343.54 |