- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $263.03 / $309.03
| Professional | | $251.19 | $263.03 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $1,288.25 / $1,288.25
| Facility | | $263.03 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $588.84 / $1,479.11
| Professional | | $263.03 | $588.84 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $281.84 / $288.40
| Professional | | $263.03 | $281.84 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $407.38 / $416.87
| Professional | | $288.40 | $407.38 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $295.12 / $575.44
| Professional | | $208.93 | $295.12 | $575.44 |