- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.65 / $1,038.83 / $1,038.83
| Professional | | $212.65 | $1,038.83 | $1,038.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.52 / $864.06 / $1,368.80
| Facility | | $227.52 | $864.06 | $1,368.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.07 / $209.55 / $1,388.54
| Professional | | $144.07 | $209.55 | $1,388.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.36 / $191.36 / $191.36
| Professional | | $191.36 | $191.36 | $191.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $233.92 / $304.08 / $460.10
| Facility | | $233.92 | $304.08 | $460.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.74 / $227.47 / $392.50
| Professional | | $190.74 | $227.47 | $392.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.74 / $222.71 / $385.53
| Professional | | $190.74 | $222.71 | $385.53 |