- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.97 / $602.34 / $1,286.08
| Professional | | $542.97 | $602.34 | $1,286.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $560.22 / $560.22 / $1,450.32
| Facility | | $560.22 | $560.22 | $1,450.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.14 / $498.14 / $560.22
| Professional | | $498.14 | $498.14 | $560.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $560.22 / $560.22 / $1,450.32
| Facility | | $560.22 | $560.22 | $1,450.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.14 / $540.42 / $704.91
| Professional | | $498.14 | $540.42 | $704.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.14 / $498.14 / $498.14
| Professional | | $498.14 | $498.14 | $498.14 |