- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.79 / $1,010.26 / $1,010.26
| Professional | | $181.79 | $1,010.26 | $1,010.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.01 / $301.60 / $908.24
| Facility | | $239.01 | $301.60 | $908.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.82 / $243.97 / $475.33
| Professional | | $131.82 | $243.97 | $475.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.01 / $301.60 / $908.24
| Facility | | $239.01 | $301.60 | $908.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.62 / $224.11 / $350.67
| Professional | | $151.62 | $224.11 | $350.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.69 / $187.77 / $327.01
| Professional | | $149.69 | $187.77 | $327.01 |