- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $657.14 / $657.14 / $657.14
| Facility | | $657.14 | $657.14 | $657.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.14 / $657.14 / $657.14
| Professional | | $657.14 | $657.14 | $657.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.10 / $485.10 / $485.10
| Professional | | $485.10 | $485.10 | $485.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,261.83 / $1,397.92 / $1,597.62
| Facility | | $1,261.83 | $1,397.92 | $1,597.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.30 / $416.30 / $520.38
| Professional | | $416.30 | $416.30 | $520.38 |