- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.13 / $1,425.96 / $1,425.96
| Professional | | $411.13 | $1,425.96 | $1,425.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.78 / $515.98 / $515.98
| Facility | | $239.78 | $515.98 | $515.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.78 / $419.60 / $515.98
| Professional | | $239.78 | $419.60 | $515.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.66 / $491.41 / $515.98
| Facility | | $206.66 | $491.41 | $515.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.78 / $387.26 / $516.35
| Professional | | $239.78 | $387.26 | $516.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.14 / $184.93 / $293.29
| Professional | | $167.14 | $184.93 | $293.29 |