- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.26 / $1,158.81 / $1,158.81
| Professional | | $158.26 | $1,158.81 | $1,158.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.22 / $316.27 / $316.27
| Facility | | $188.22 | $316.27 | $316.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.22 / $257.20 / $316.27
| Professional | | $188.22 | $257.20 | $316.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.94 / $301.22 / $316.27
| Facility | | $167.94 | $301.22 | $316.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.22 / $237.38 / $337.25
| Professional | | $188.22 | $237.38 | $337.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.82 / $150.28 / $175.84
| Professional | | $135.82 | $150.28 | $175.84 |