- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $617.41 / $2,015.11 / $3,951.31
| Facility | | $617.41 | $2,015.11 | $3,951.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $617.41 / $617.41 / $617.41
| Professional | | $617.41 | $617.41 | $617.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.84 / $68.84 / $68.84
| Professional | | $68.84 | $68.84 | $68.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $617.41 / $642.36 / $871.93
| Facility | | $617.41 | $642.36 | $871.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.02 / $1,031.02 / $1,031.02
| Professional | | $1,031.02 | $1,031.02 | $1,031.02 |