- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $509.46 / $509.46 / $509.46
| Facility | | $509.46 | $509.46 | $509.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $509.46 / $674.38 / $674.38
| Professional | | $509.46 | $674.38 | $674.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $765.78 / $765.78 / $765.78
| Facility | | $765.78 | $765.78 | $765.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.34 / $806.53 / $3,150.93
| Professional | | $211.34 | $806.53 | $3,150.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.98 / $544.29 / $1,079.10
| Professional | | $211.98 | $544.29 | $1,079.10 |