- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.85 / $2,116.55 / $2,116.55
| Professional | | $362.85 | $2,116.55 | $2,116.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $667.24 / $667.24 / $667.24
| Facility | | $667.24 | $667.24 | $667.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.10 / $667.24 / $675.12
| Professional | | $392.10 | $667.24 | $675.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.06 / $667.24 / $667.92
| Facility | | $326.06 | $667.24 | $667.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.73 / $605.65 / $873.60
| Professional | | $403.73 | $605.65 | $873.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.71 / $691.94 / $1,166.43
| Professional | | $560.71 | $691.94 | $1,166.43 |