- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $389.05 / $1,047.13
| Professional | | $263.03 | $389.05 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $676.08
| Facility | | $524.81 | $524.81 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $1,148.15
| Professional | | $363.08 | $363.08 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $416.87 / $616.60
| Professional | | $269.15 | $416.87 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $426.58 / $524.81
| Professional | | $316.23 | $426.58 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $398.11 / $741.31
| Professional | | $323.59 | $398.11 | $741.31 |