- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.60 / $2,669.33 / $2,669.33
| Professional | | $769.60 | $2,669.33 | $2,669.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.58 / $971.43 / $971.43
| Facility | | $500.58 | $971.43 | $971.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.58 / $789.97 / $971.43
| Professional | | $500.58 | $789.97 | $971.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $386.85 / $925.17 / $971.43
| Facility | | $386.85 | $925.17 | $971.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.58 / $729.10 / $972.13
| Professional | | $500.58 | $729.10 | $972.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.87 / $346.16 / $533.42
| Professional | | $312.87 | $346.16 | $533.42 |