- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Professional | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $630.96
| Facility | | $575.44 | $602.56 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $562.34 / $724.44
| Professional | | $416.87 | $562.34 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,570.88 / $5,128.61
| Professional | | $4,168.69 | $4,570.88 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $416.87 / $1,096.48
| Facility | | $302.00 | $416.87 | $1,096.48 |