- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.73 / $1,091.58 / $1,091.58
| Professional | | $314.73 | $1,091.58 | $1,091.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.81 / $501.06 / $501.06
| Facility | | $297.81 | $501.06 | $501.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.81 / $407.46 / $501.06
| Professional | | $297.81 | $407.46 | $501.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.54 / $477.20 / $501.06
| Facility | | $199.54 | $477.20 | $501.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.81 / $376.07 / $501.42
| Professional | | $297.81 | $376.07 | $501.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.38 / $178.55 / $275.14
| Professional | | $161.38 | $178.55 | $275.14 |