- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.42 / $768.42 / $1,345.70
| Professional | | $768.42 | $768.42 | $1,345.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,500.81 / $1,500.81 / $1,500.81
| Facility | | $1,500.81 | $1,500.81 | $1,500.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.81 / $1,500.81 / $1,500.81
| Professional | | $1,500.81 | $1,500.81 | $1,500.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.21 / $812.21 / $1,496.31
| Facility | | $812.21 | $812.21 | $1,496.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $592.91 / $592.91 / $812.21
| Professional | | $592.91 | $592.91 | $812.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.72 / $575.03 / $1,152.61
| Professional | | $519.72 | $575.03 | $1,152.61 |