- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.02 / $435.35 / $1,045.60
| Professional | | $66.02 | $435.35 | $1,045.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.73 / $167.73 / $199.38
| Facility | | $167.73 | $167.73 | $199.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.96 / $167.73 / $252.01
| Professional | | $150.96 | $167.73 | $252.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.02 / $167.73 / $1,045.60
| Facility | | $66.02 | $167.73 | $1,045.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.73 / $167.73 / $732.55
| Professional | | $167.73 | $167.73 | $732.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.47 / $1,129.19 / $1,698.23
| Professional | | $1,096.47 | $1,129.19 | $1,698.23 |