- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.15 / $1,113.48 / $1,113.48
| Professional | | $199.15 | $1,113.48 | $1,113.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.10 / $294.39 / $987.07
| Facility | | $251.10 | $294.39 | $987.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.24 / $251.10 / $251.10
| Professional | | $102.24 | $251.10 | $251.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.10 / $294.39 / $987.07
| Facility | | $251.10 | $294.39 | $987.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.85 / $155.85 / $251.10
| Professional | | $155.85 | $155.85 | $251.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.90 / $103.90 / $190.49
| Professional | | $103.90 | $103.90 | $190.49 |