- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.87 / $229.22 / $1,285.63
| Professional | | $225.87 | $229.22 | $1,285.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.32 / $398.68 / $1,122.22
| Facility | | $295.32 | $398.68 | $1,122.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.85 / $331.78 / $646.42
| Professional | | $134.85 | $331.78 | $646.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.32 / $398.68 / $1,122.22
| Facility | | $295.32 | $398.68 | $1,122.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.60 / $282.77 / $383.57
| Professional | | $199.60 | $282.77 | $383.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.32 / $193.26 / $393.60
| Professional | | $173.32 | $193.26 | $393.60 |