- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.15 / $244.26 / $1,632.38
| Professional | | $196.15 | $244.26 | $1,632.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $395.40 / $395.40 / $395.40
| Facility | | $395.40 | $395.40 | $395.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.83 / $395.40 / $1,004.24
| Professional | | $260.83 | $395.40 | $1,004.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.60 / $305.75 / $509.20
| Facility | | $180.60 | $305.75 | $509.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.71 / $343.11 / $494.90
| Professional | | $228.71 | $343.11 | $494.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.10 / $367.30 / $499.79
| Professional | | $307.10 | $367.30 | $499.79 |