- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.71 / $208.71 / $1,394.25
| Professional | | $208.71 | $208.71 | $1,394.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $310.87 / $310.87 / $416.18
| Facility | | $310.87 | $310.87 | $416.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.24 / $310.87 / $543.75
| Professional | | $264.24 | $310.87 | $543.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.71 / $301.52 / $436.48
| Professional | | $207.71 | $301.52 | $436.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.71 / $273.56 / $463.80
| Professional | | $208.71 | $273.56 | $463.80 |