- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $413.81 / $413.81 / $413.81
| Facility | | $413.81 | $413.81 | $413.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $413.81 / $515.22 / $515.22
| Professional | | $413.81 | $515.22 | $515.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $626.79 / $626.79 / $626.79
| Facility | | $626.79 | $626.79 | $626.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.46 / $688.75 / $2,627.09
| Professional | | $437.46 | $688.75 | $2,627.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.16 / $514.09 / $863.75
| Professional | | $327.16 | $514.09 | $863.75 |