- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.98 / $1,190.83 / $1,190.83
| Professional | | $212.98 | $1,190.83 | $1,190.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $268.54 / $314.83 / $1,055.64
| Facility | | $268.54 | $314.83 | $1,055.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.44 / $268.54 / $268.54
| Professional | | $87.44 | $268.54 | $268.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $268.54 / $314.83 / $1,055.64
| Facility | | $268.54 | $314.83 | $1,055.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.68 / $166.68 / $268.54
| Professional | | $166.68 | $166.68 | $268.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.78 / $77.78 / $185.20
| Professional | | $77.78 | $77.78 | $185.20 |