- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $1,371.52 / $1,371.52
| Professional | | $245.30 | $1,371.52 | $1,371.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.82 / $285.82 / $285.82
| Professional | | $285.82 | $285.82 | $285.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.29 / $362.61 / $1,215.81
| Facility | | $309.29 | $362.61 | $1,215.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.29 / $309.29 / $309.29
| Professional | | $309.29 | $309.29 | $309.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.29 / $362.61 / $1,215.81
| Facility | | $309.29 | $362.61 | $1,215.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.97 / $191.97 / $309.29
| Professional | | $191.97 | $191.97 | $309.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.62 / $89.59 / $151.71
| Professional | | $63.62 | $89.59 | $151.71 |