- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.97 / $5,125.35 / $5,125.35
| Professional | | $699.97 | $5,125.35 | $5,125.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $832.50 / $1,572.36 / $1,572.36
| Facility | | $832.50 | $1,572.36 | $1,572.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.50 / $1,278.66 / $1,572.36
| Professional | | $832.50 | $1,278.66 | $1,572.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $742.79 / $1,497.49 / $1,572.36
| Facility | | $742.79 | $1,497.49 | $1,572.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.50 / $1,180.13 / $1,573.50
| Professional | | $832.50 | $1,180.13 | $1,573.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.74 / $664.67 / $760.87
| Professional | | $600.74 | $664.67 | $760.87 |