- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.22 / $1,158.59 / $1,158.59
| Professional | | $158.22 | $1,158.59 | $1,158.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.19 / $316.23 / $316.23
| Facility | | $188.19 | $316.23 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.19 / $257.16 / $316.23
| Professional | | $188.19 | $257.16 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.91 / $301.17 / $316.23
| Facility | | $167.91 | $301.17 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.19 / $237.35 / $316.45
| Professional | | $188.19 | $237.35 | $316.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.80 / $150.25 / $172.00
| Professional | | $135.80 | $150.25 | $172.00 |