- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $1,281.98 / $1,281.98
| Professional | | $200.00 | $1,281.98 | $1,281.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.74 / $333.45 / $1,074.91
| Facility | | $269.74 | $333.45 | $1,074.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.93 / $269.74 / $524.55
| Professional | | $172.93 | $269.74 | $524.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.74 / $333.45 / $1,074.91
| Facility | | $269.74 | $333.45 | $1,074.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.93 / $246.57 / $372.48
| Professional | | $172.93 | $246.57 | $372.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.65 / $197.21 / $392.96
| Professional | | $178.65 | $197.21 | $392.96 |