- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.16 / $1,675.12 / $1,675.12
| Professional | | $297.16 | $1,675.12 | $1,675.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $385.73 / $492.70 / $1,465.76
| Facility | | $385.73 | $492.70 | $1,465.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.65 / $398.56 / $776.10
| Professional | | $212.65 | $398.56 | $776.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $385.73 / $492.70 / $1,465.76
| Facility | | $385.73 | $492.70 | $1,465.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.40 / $366.64 / $486.06
| Professional | | $247.40 | $366.64 | $486.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.43 / $251.36 / $512.10
| Professional | | $247.43 | $251.36 | $512.10 |