- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.15 / $171.15 / $171.15
| Facility | | $171.15 | $171.15 | $171.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.15 / $171.15 / $392.08
| Professional | | $171.15 | $171.15 | $392.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,935.29 / $3,016.92 / $4,722.57
| Facility | | $1,935.29 | $3,016.92 | $4,722.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.15 / $171.15 / $244.74
| Facility | | $171.15 | $171.15 | $244.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.26 / $427.26 / $427.26
| Professional | | $427.26 | $427.26 | $427.26 |