- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.48 / $489.26 / $489.26
| Professional | | $460.48 | $489.26 | $489.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $555.79 / $913.06 / $1,020.86
| Facility | | $555.79 | $913.06 | $1,020.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.43 / $508.43 / $508.43
| Facility | | $508.43 | $508.43 | $508.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.43 / $508.43 / $508.43
| Professional | | $508.43 | $508.43 | $508.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.60 / $575.60 / $621.05
| Professional | | $575.60 | $575.60 | $621.05 |