- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.56 / $1,212.86 / $1,212.86
| Professional | | $218.56 | $1,212.86 | $1,212.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.97 / $336.11 / $946.09
| Facility | | $248.97 | $336.11 | $946.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.36 / $303.91 / $590.38
| Professional | | $197.36 | $303.91 | $590.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.97 / $336.11 / $946.09
| Facility | | $248.97 | $336.11 | $946.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.89 / $269.02 / $367.85
| Professional | | $189.89 | $269.02 | $367.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.21 / $180.38 / $372.68
| Professional | | $148.21 | $180.38 | $372.68 |