- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.81 / $1,008.23 / $1,008.23
| Professional | | $752.81 | $1,008.23 | $1,008.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $396.70 / $396.70 / $396.70
| Facility | | $396.70 | $396.70 | $396.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.20 / $396.70 / $408.60
| Professional | | $337.20 | $396.70 | $408.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $396.70 / $396.70 / $396.70
| Facility | | $396.70 | $396.70 | $396.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.70 / $396.70 / $408.60
| Professional | | $396.70 | $396.70 | $408.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.16 / $886.51 / $1,489.33
| Professional | | $175.16 | $886.51 | $1,489.33 |