- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.17 / $408.65 / $2,154.85
| Professional | | $323.17 | $408.65 | $2,154.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $655.67 / $655.67 / $655.67
| Facility | | $655.67 | $655.67 | $655.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.44 / $582.41 / $1,091.32
| Professional | | $396.44 | $582.41 | $1,091.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $322.47 / $527.53 / $740.03
| Facility | | $322.47 | $527.53 | $740.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.30 / $658.36 / $1,097.07
| Professional | | $408.30 | $658.36 | $1,097.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $551.30 / $680.34 / $846.66
| Professional | | $551.30 | $680.34 | $846.66 |