- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.33 / $1,507.79 / $1,507.79
| Professional | | $276.33 | $1,507.79 | $1,507.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $329.96 / $445.44 / $1,253.83
| Facility | | $329.96 | $445.44 | $1,253.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.47 / $382.26 / $743.60
| Professional | | $182.47 | $382.26 | $743.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $329.96 / $445.44 / $1,253.83
| Facility | | $329.96 | $445.44 | $1,253.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.62 / $340.52 / $462.80
| Professional | | $236.62 | $340.52 | $462.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.53 / $223.93 / $462.67
| Professional | | $201.53 | $223.93 | $462.67 |