- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.16 / $1,421.69 / $1,421.69
| Professional | | $194.16 | $1,421.69 | $1,421.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.92 / $467.07 / $467.07
| Facility | | $230.92 | $467.07 | $467.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.92 / $379.82 / $467.07
| Professional | | $230.92 | $379.82 | $467.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.03 / $444.83 / $467.07
| Facility | | $206.03 | $444.83 | $467.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.92 / $350.55 / $467.40
| Professional | | $230.92 | $350.55 | $467.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.63 / $184.37 / $282.13
| Professional | | $166.63 | $184.37 | $282.13 |