- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.17 / $216.16 / $1,212.98
| Professional | | $206.17 | $216.16 | $1,212.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.47 / $376.47 / $376.47
| Facility | | $376.47 | $376.47 | $376.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.58 / $376.47 / $376.47
| Professional | | $271.58 | $376.47 | $376.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.84 / $382.85 / $399.74
| Facility | | $184.84 | $382.85 | $399.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.10 / $340.68 / $491.40
| Professional | | $227.10 | $340.68 | $491.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.18 / $409.46 / $657.68
| Professional | | $326.18 | $409.46 | $657.68 |