- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $590.36 / $2,361.44 / $2,361.44
| Facility | | $590.36 | $2,361.44 | $2,361.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.36 / $590.36 / $590.36
| Professional | | $590.36 | $590.36 | $590.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.65 / $511.65 / $511.65
| Facility | | $511.65 | $511.65 | $511.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.08 / $1,283.05 / $1,283.05
| Professional | | $1,220.08 | $1,283.05 | $1,283.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.65 / $511.65 / $991.81
| Facility | | $511.65 | $511.65 | $991.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.44 / $830.44 / $944.58
| Professional | | $830.44 | $830.44 | $944.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.60 / $330.60 / $472.29
| Professional | | $330.60 | $330.60 | $472.29 |