- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.20 / $412.10 / $2,179.60
| Professional | | $313.20 | $412.10 | $2,179.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $675.65 / $675.65 / $675.65
| Facility | | $675.65 | $675.65 | $675.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.47 / $601.79 / $1,063.98
| Professional | | $359.47 | $601.79 | $1,063.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $413.98 / $525.57 / $715.36
| Facility | | $413.98 | $525.57 | $715.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.20 / $683.71 / $1,139.30
| Professional | | $410.20 | $683.71 | $1,139.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.04 / $661.71 / $876.98
| Professional | | $571.04 | $661.71 | $876.98 |