- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.45 / $1,252.11 / $1,252.11
| Professional | | $224.45 | $1,252.11 | $1,252.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.20 / $370.17 / $1,041.96
| Facility | | $274.20 | $370.17 | $1,041.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.33 / $310.75 / $604.53
| Professional | | $167.33 | $310.75 | $604.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.20 / $370.17 / $1,041.96
| Facility | | $274.20 | $370.17 | $1,041.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.38 / $276.35 / $376.65
| Professional | | $192.38 | $276.35 | $376.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.04 / $185.90 / $384.08
| Professional | | $185.04 | $185.90 | $384.08 |