- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.11 / $311.27 / $546.67
| Professional | | $208.11 | $311.27 | $546.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $939.37 / $939.37 / $1,203.05
| Facility | | $939.37 | $939.37 | $1,203.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.80 / $431.99 / $1,223.42
| Professional | | $355.80 | $431.99 | $1,223.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.37 / $426.20 / $1,199.09
| Professional | | $284.37 | $426.20 | $1,199.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.48 / $470.55 / $1,199.09
| Professional | | $296.48 | $470.55 | $1,199.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.40 / $400.05 / $1,338.88
| Professional | | $334.40 | $400.05 | $1,338.88 |