- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $312.73 / $312.73 / $312.73
| Facility | | $312.73 | $312.73 | $312.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.73 / $394.68 / $394.68
| Professional | | $312.73 | $394.68 | $394.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $476.51 / $476.51 / $476.51
| Facility | | $476.51 | $476.51 | $476.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.82 / $526.62 / $1,997.22
| Professional | | $301.82 | $526.62 | $1,997.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.64 / $347.64 / $623.58
| Professional | | $244.64 | $347.64 | $623.58 |