- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.15 / $260.08 / $1,020.85
| Professional | | $194.15 | $260.08 | $1,020.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $305.49 / $305.49 / $305.49
| Facility | | $305.49 | $305.49 | $305.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.47 / $284.60 / $305.49
| Professional | | $154.47 | $284.60 | $305.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.72 / $207.25 / $305.49
| Facility | | $150.72 | $207.25 | $305.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.66 / $285.45 / $403.90
| Professional | | $186.66 | $285.45 | $403.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.36 / $319.76 / $361.90
| Professional | | $271.36 | $319.76 | $361.90 |