- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $416.87 / $602.56
| Professional | | $263.03 | $416.87 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $933.25 / $1,380.38
| Facility | | $776.25 | $933.25 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,230.27 / $2,187.76
| Facility | | $812.83 | $1,230.27 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Facility | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Professional | | $1,949.84 | $1,949.84 | $1,949.84 |