- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.88 / $1,419.51 / $1,419.51
| Professional | | $258.88 | $1,419.51 | $1,419.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.76 / $433.03 / $1,218.89
| Facility | | $320.76 | $433.03 | $1,218.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.55 / $357.02 / $695.17
| Professional | | $205.55 | $357.02 | $695.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.76 / $433.03 / $1,218.89
| Facility | | $320.76 | $433.03 | $1,218.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.54 / $318.98 / $433.87
| Professional | | $221.54 | $318.98 | $433.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.20 / $216.69 / $434.78
| Professional | | $196.20 | $216.69 | $434.78 |