- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.47 / $371.47 / $371.47
| Facility | | $371.47 | $371.47 | $371.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.47 / $405.97 / $405.97
| Professional | | $371.47 | $405.97 | $405.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $453.72 / $1,391.62 / $1,709.52
| Facility | | $453.72 | $1,391.62 | $1,709.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.24 / $478.34 / $1,855.31
| Professional | | $292.24 | $478.34 | $1,855.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.18 / $361.43 / $673.88
| Professional | | $227.18 | $361.43 | $673.88 |