- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.86 / $1,110.19 / $1,619.74
| Professional | | $203.86 | $1,110.19 | $1,619.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $314.43 / $314.43 / $314.43
| Facility | | $314.43 | $314.43 | $314.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.43 / $380.63 / $537.77
| Professional | | $303.43 | $380.63 | $537.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.76 / $510.25 / $570.52
| Facility | | $197.76 | $510.25 | $570.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.94 / $314.43 / $537.77
| Professional | | $202.94 | $314.43 | $537.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.73 / $506.81 / $804.75
| Professional | | $403.73 | $506.81 | $804.75 |