- 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
- $15.00 / $617.41 / $817.27
| Professional | | $15.00 | $617.41 | $817.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $449.96 / $721.43 / $828.56
| Facility | | $449.96 | $721.43 | $828.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.28 / $140.35 / $140.35
| Professional | | $112.28 | $140.35 | $140.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $617.41 / $617.41 / $1,564.69
| Facility | | $617.41 | $617.41 | $1,564.69 |
- 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 |