- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.89 / $1,190.32 / $1,190.32
| Professional | | $212.89 | $1,190.32 | $1,190.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.06 / $248.06 / $248.06
| Professional | | $248.06 | $248.06 | $248.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $268.42 / $314.70 / $1,055.18
| Facility | | $268.42 | $314.70 | $1,055.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.42 / $268.42 / $268.42
| Professional | | $268.42 | $268.42 | $268.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $268.42 / $314.70 / $1,055.18
| Facility | | $268.42 | $314.70 | $1,055.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.61 / $166.61 / $268.42
| Professional | | $166.61 | $166.61 | $268.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.75 / $77.75 / $185.12
| Professional | | $77.75 | $77.75 | $185.12 |