- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.80 / $575.14 / $2,224.81
| Professional | | $431.80 | $575.14 | $2,224.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $682.49 / $682.49 / $682.49
| Facility | | $682.49 | $682.49 | $682.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.31 / $682.49 / $727.50
| Professional | | $370.31 | $682.49 | $727.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $336.27 / $462.37 / $682.49
| Facility | | $336.27 | $462.37 | $682.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.37 / $682.49 / $908.60
| Professional | | $415.37 | $682.49 | $908.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $617.10 / $713.90 / $796.81
| Professional | | $617.10 | $713.90 | $796.81 |