- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.20 / $300.64 / $369.93
| Professional | | $252.20 | $300.64 | $369.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,416.67 / $1,416.67 / $1,504.86
| Facility | | $1,416.67 | $1,416.67 | $1,504.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.80 / $395.57 / $1,147.59
| Professional | | $319.80 | $395.57 | $1,147.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.62 / $369.62 / $914.13
| Professional | | $266.62 | $369.62 | $914.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.06 / $463.05 / $914.13
| Professional | | $335.06 | $463.05 | $914.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.06 / $388.81 / $1,298.71
| Professional | | $335.06 | $388.81 | $1,298.71 |