- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.60 / $1,854.26 / $1,854.26
| Professional | | $534.60 | $1,854.26 | $1,854.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $365.10 / $506.10 / $506.10
| Facility | | $365.10 | $506.10 | $506.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.10 / $411.57 / $506.10
| Professional | | $365.10 | $411.57 | $506.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $268.73 / $482.00 / $506.10
| Facility | | $268.73 | $482.00 | $506.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.10 / $379.85 / $527.36
| Professional | | $365.10 | $379.85 | $527.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.34 / $240.46 / $381.37
| Professional | | $217.34 | $240.46 | $381.37 |