- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.24 / $1,644.88 / $1,644.88
| Professional | | $474.24 | $1,644.88 | $1,644.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $298.85 / $502.18 / $502.18
| Facility | | $298.85 | $502.18 | $502.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.85 / $408.38 / $502.18
| Professional | | $298.85 | $408.38 | $502.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $266.64 / $478.27 / $502.18
| Facility | | $266.64 | $478.27 | $502.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.85 / $376.91 / $550.01
| Professional | | $298.85 | $376.91 | $550.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.65 / $238.60 / $367.68
| Professional | | $215.65 | $238.60 | $367.68 |