- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.83 / $1,185.01 / $1,185.01
| Professional | | $161.83 | $1,185.01 | $1,185.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.11 / $520.14 / $520.14
| Facility | | $246.11 | $520.14 | $520.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.11 / $422.98 / $520.14
| Professional | | $246.11 | $422.98 | $520.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219.58 / $495.37 / $520.14
| Facility | | $219.58 | $495.37 | $520.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.11 / $390.38 / $520.51
| Professional | | $246.11 | $390.38 | $520.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.59 / $196.49 / $224.93
| Professional | | $177.59 | $196.49 | $224.93 |