- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.01 / $1,033.72 / $1,033.72
| Professional | | $186.01 | $1,033.72 | $1,033.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.98 / $318.57 / $896.72
| Facility | | $235.98 | $318.57 | $896.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.47 / $258.17 / $502.80
| Professional | | $119.47 | $258.17 | $502.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.98 / $318.57 / $896.72
| Facility | | $235.98 | $318.57 | $896.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.29 / $229.15 / $313.14
| Professional | | $160.29 | $229.15 | $313.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.63 / $153.08 / $316.27
| Professional | | $131.63 | $153.08 | $316.27 |