- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.43 / $312.38 / $1,815.71
| Professional | | $209.43 | $312.38 | $1,815.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $350.18 / $350.18 / $350.18
| Facility | | $350.18 | $350.18 | $350.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.26 / $394.91 / $806.20
| Professional | | $268.26 | $394.91 | $806.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.37 / $350.18 / $642.16
| Facility | | $230.37 | $350.18 | $642.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.82 / $516.69 / $836.48
| Professional | | $301.82 | $516.69 | $836.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $466.14 / $572.32 / $695.08
| Professional | | $466.14 | $572.32 | $695.08 |