- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.31 / $1,322.56 / $1,322.56
| Professional | | $381.31 | $1,322.56 | $1,322.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $417.27 / $417.27 / $417.27
| Professional | | $417.27 | $417.27 | $417.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $277.45 / $448.64 / $448.64
| Facility | | $277.45 | $448.64 | $448.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.45 / $364.84 / $448.64
| Professional | | $277.45 | $364.84 | $448.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $277.45 / $427.28 / $448.64
| Facility | | $277.45 | $427.28 | $448.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.45 / $336.74 / $448.98
| Professional | | $277.45 | $336.74 | $448.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.74 / $188.91 / $339.62
| Professional | | $170.74 | $188.91 | $339.62 |