- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.73 / $2,125.23 / $2,125.23
| Professional | | $612.73 | $2,125.23 | $2,125.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.56 / $676.46 / $676.46
| Facility | | $402.56 | $676.46 | $676.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.56 / $550.10 / $676.46
| Professional | | $402.56 | $550.10 | $676.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $359.18 / $644.25 / $676.46
| Facility | | $359.18 | $644.25 | $676.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.56 / $507.71 / $740.89
| Professional | | $402.56 | $507.71 | $740.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.49 / $321.41 / $509.75
| Professional | | $290.49 | $321.41 | $509.75 |