- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $617.41 / $617.41 / $617.41
| Facility | | $617.41 | $617.41 | $617.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $617.41 / $617.41 / $817.27
| Professional | | $617.41 | $617.41 | $817.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $824.69 / $1,505.06 / $2,235.64
| Facility | | $824.69 | $1,505.06 | $2,235.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $744.63 / $744.63 / $744.63
| Professional | | $744.63 | $744.63 | $744.63 |