- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.28 / $1,208.25 / $1,208.25
| Professional | | $216.28 | $1,208.25 | $1,208.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $272.58 / $360.10 / $1,035.80
| Facility | | $272.58 | $360.10 | $1,035.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.64 / $291.29 / $566.79
| Professional | | $202.64 | $291.29 | $566.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $272.58 / $360.10 / $1,035.80
| Facility | | $272.58 | $360.10 | $1,035.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.28 / $266.73 / $416.51
| Professional | | $188.28 | $266.73 | $416.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.15 / $220.34 / $383.72
| Professional | | $179.15 | $220.34 | $383.72 |