- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.92 / $1,765.15 / $1,765.15
| Professional | | $508.92 | $1,765.15 | $1,765.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $405.51 / $665.45 / $665.45
| Facility | | $405.51 | $665.45 | $665.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $405.51 / $541.16 / $665.45
| Professional | | $405.51 | $541.16 | $665.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $312.20 / $633.76 / $665.45
| Facility | | $312.20 | $633.76 | $665.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $405.51 / $499.46 / $665.94
| Professional | | $405.51 | $499.46 | $665.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.49 / $279.36 / $430.49
| Professional | | $252.49 | $279.36 | $430.49 |