- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.34 / $340.34 / $680.68
| Facility | | $340.34 | $340.34 | $680.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.34 / $382.35 / $415.05
| Professional | | $340.34 | $382.35 | $415.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $483.67 / $483.67 / $483.67
| Facility | | $483.67 | $483.67 | $483.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.16 / $565.71 / $2,008.11
| Professional | | $398.16 | $565.71 | $2,008.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $958.14 / $958.14 / $958.14
| Professional | | $958.14 | $958.14 | $958.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.88 / $512.38 / $861.02
| Professional | | $261.88 | $512.38 | $861.02 |