- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.10 / $1,377.35 / $1,377.35
| Professional | | $188.10 | $1,377.35 | $1,377.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.07 / $501.25 / $501.25
| Facility | | $227.07 | $501.25 | $501.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.07 / $407.62 / $501.25
| Professional | | $227.07 | $407.62 | $501.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.61 / $477.38 / $501.25
| Facility | | $199.61 | $477.38 | $501.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.07 / $376.21 / $501.61
| Professional | | $227.07 | $376.21 | $501.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.44 / $178.62 / $297.70
| Professional | | $161.44 | $178.62 | $297.70 |