- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $585.04 / $585.04 / $585.04
| Facility | | $585.04 | $585.04 | $585.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.04 / $585.04 / $603.50
| Professional | | $585.04 | $585.04 | $603.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $668.29 / $1,201.34 / $1,723.75
| Facility | | $668.29 | $1,201.34 | $1,723.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $603.87 / $603.87 / $603.87
| Facility | | $603.87 | $603.87 | $603.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.73 / $1,000.73 / $1,000.73
| Professional | | $1,000.73 | $1,000.73 | $1,000.73 |