- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $787.15 / $1,440.48 / $1,944.65
| Facility | | $787.15 | $1,440.48 | $1,944.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.85 / $621.85 / $621.85
| Professional | | $621.85 | $621.85 | $621.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.30 / $1,062.65 / $1,062.65
| Facility | | $1,023.30 | $1,062.65 | $1,062.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.65 / $511.65 / $537.23
| Facility | | $511.65 | $511.65 | $537.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Professional | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.60 / $472.29 / $1,180.73
| Professional | | $330.60 | $472.29 | $1,180.73 |