- 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
- $1,935.29 / $3,005.71 / $4,765.84
| Facility | | $1,935.29 | $3,005.71 | $4,765.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $617.41 / $617.41 / $759.43
| Facility | | $617.41 | $617.41 | $759.43 |
- 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 |