- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.32 / $1,157.93 / $1,157.93
| Professional | | $222.32 | $1,157.93 | $1,157.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $264.68 / $357.31 / $1,005.77
| Facility | | $264.68 | $357.31 | $1,005.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.52 / $297.60 / $579.41
| Professional | | $116.52 | $297.60 | $579.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $264.68 / $357.31 / $1,005.77
| Facility | | $264.68 | $357.31 | $1,005.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.59 / $255.55 / $357.97
| Professional | | $184.59 | $255.55 | $357.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.00 / $171.79 / $354.92
| Professional | | $152.00 | $171.79 | $354.92 |