- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.86 / $2,247.07 / $2,247.07
| Professional | | $647.86 | $2,247.07 | $2,247.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $503.81 / $817.75 / $817.75
| Facility | | $503.81 | $817.75 | $817.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.81 / $817.75 / $817.75
| Professional | | $503.81 | $817.75 | $817.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $325.66 / $778.81 / $817.75
| Facility | | $325.66 | $778.81 | $817.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.29 / $613.76 / $818.35
| Professional | | $585.29 | $613.76 | $818.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.38 / $291.41 / $462.17
| Professional | | $263.38 | $291.41 | $462.17 |