- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.60 / $1,562.89 / $1,562.89
| Professional | | $450.60 | $1,562.89 | $1,562.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $280.67 / $426.57 / $426.57
| Facility | | $280.67 | $426.57 | $426.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.67 / $346.90 / $426.57
| Professional | | $280.67 | $346.90 | $426.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $226.50 / $406.26 / $426.57
| Facility | | $226.50 | $406.26 | $426.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.67 / $320.17 / $444.68
| Professional | | $280.67 | $320.17 | $444.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.19 / $202.68 / $321.45
| Professional | | $183.19 | $202.68 | $321.45 |