- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.02 / $304.77 / $1,293.63
| Professional | | $220.02 | $304.77 | $1,293.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.04 / $368.55 / $1,037.40
| Facility | | $225.04 | $368.55 | $1,037.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.43 / $246.71 / $475.22
| Professional | | $214.43 | $246.71 | $475.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.65 / $278.20 / $537.80
| Facility | | $119.65 | $278.20 | $537.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.92 / $318.77 / $531.91
| Professional | | $170.92 | $318.77 | $531.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.06 / $229.72 / $396.76
| Professional | | $223.06 | $229.72 | $396.76 |