- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.47 / $1,613.22 / $1,613.22
| Professional | | $351.47 | $1,613.22 | $1,613.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.61 / $501.61 / $501.61
| Facility | | $501.61 | $501.61 | $501.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.79 / $501.61 / $501.61
| Professional | | $307.79 | $501.61 | $501.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.50 / $501.61 / $544.58
| Facility | | $500.50 | $501.61 | $544.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.44 / $429.89 / $656.60
| Professional | | $303.44 | $429.89 | $656.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.11 / $528.64 / $872.28
| Professional | | $421.11 | $528.64 | $872.28 |