- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.49 / $1,548.63 / $1,548.63
| Professional | | $336.49 | $1,548.63 | $1,548.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $486.37 / $486.37 / $486.37
| Facility | | $486.37 | $486.37 | $486.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.16 / $486.37 / $486.37
| Professional | | $299.16 | $486.37 | $486.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.06 / $486.37 / $504.10
| Facility | | $238.06 | $486.37 | $504.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.06 / $441.14 / $636.29
| Professional | | $294.06 | $441.14 | $636.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.51 / $483.15 / $851.92
| Professional | | $391.51 | $483.15 | $851.92 |