- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.35 / $274.27 / $1,004.76
| Professional | | $202.35 | $274.27 | $1,004.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.01 / $316.01 / $316.01
| Facility | | $316.01 | $316.01 | $316.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.76 / $311.27 / $316.01
| Professional | | $155.76 | $311.27 | $316.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.40 / $195.50 / $316.01
| Facility | | $156.40 | $195.50 | $316.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.12 / $310.04 / $407.00
| Professional | | $190.12 | $310.04 | $407.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.08 / $301.83 / $341.89
| Professional | | $254.08 | $301.83 | $341.89 |