- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.34 / $150.34 / $1,072.47
| Professional | | $150.34 | $150.34 | $1,072.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.17 / $243.17 / $319.16
| Facility | | $243.17 | $243.17 | $319.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.69 / $243.17 / $436.13
| Professional | | $206.69 | $243.17 | $436.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.38 / $249.31 / $359.34
| Professional | | $171.38 | $249.31 | $359.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.34 / $185.44 / $334.08
| Professional | | $150.34 | $185.44 | $334.08 |