- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $451.47 / $2,650.26 / $2,650.26
| Professional | | $451.47 | $2,650.26 | $2,650.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $820.77 / $820.77 / $820.77
| Facility | | $820.77 | $820.77 | $820.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.41 / $820.77 / $820.77
| Professional | | $516.41 | $820.77 | $820.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.64 / $919.75 / $968.99
| Facility | | $402.64 | $919.75 | $968.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.57 / $744.94 / $1,074.50
| Professional | | $496.57 | $744.94 | $1,074.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $721.65 / $905.60 / $1,437.46
| Professional | | $721.65 | $905.60 | $1,437.46 |