- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.70 / $1,102.94 / $1,488.97
| Facility | | $602.70 | $1,102.94 | $1,488.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.13 / $476.13 / $476.13
| Professional | | $476.13 | $476.13 | $476.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $783.51 / $813.65 / $813.65
| Facility | | $783.51 | $813.65 | $813.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.76 / $391.76 / $411.35
| Facility | | $391.76 | $391.76 | $411.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $40.00 / $50.00
| Professional | | $21.25 | $40.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.13 / $361.62 / $904.05
| Professional | | $253.13 | $361.62 | $904.05 |