- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $360.83 / $515.34 / $1,010.04
| Facility | | $360.83 | $515.34 | $1,010.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.30 / $1,010.04 / $1,010.04
| Professional | | $271.30 | $1,010.04 | $1,010.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $913.85 / $913.85 / $913.85
| Facility | | $913.85 | $913.85 | $913.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $681.38 / $1,002.03 / $1,002.03
| Professional | | $681.38 | $1,002.03 | $1,002.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $299.25 / $447.19 / $1,047.31
| Facility | | $299.25 | $447.19 | $1,047.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.09 / $337.35 / $1,151.24
| Professional | | $145.09 | $337.35 | $1,151.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.05 / $336.68 / $480.97
| Professional | | $161.05 | $336.68 | $480.97 |