- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.83 / $312.48 / $406.49
| Professional | | $196.83 | $312.48 | $406.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $528.71 / $1,115.81 / $1,185.24
| Facility | | $528.71 | $1,115.81 | $1,185.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.26 / $414.34 / $1,220.43
| Professional | | $341.26 | $414.34 | $1,220.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.29 / $430.97 / $1,092.17
| Professional | | $269.29 | $430.97 | $1,092.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.62 / $447.18 / $1,092.17
| Professional | | $276.62 | $447.18 | $1,092.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.99 / $407.01 / $1,251.94
| Professional | | $322.99 | $407.01 | $1,251.94 |