- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.58 / $1,043.50 / $1,154.04
| Professional | | $580.58 | $1,043.50 | $1,154.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $936.57 / $936.57 / $936.57
| Facility | | $936.57 | $936.57 | $936.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.22 / $796.08 / $964.67
| Professional | | $100.22 | $796.08 | $964.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.09 / $200.16 / $1,119.10
| Facility | | $103.09 | $200.16 | $1,119.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.22 / $168.02 / $936.57
| Professional | | $100.22 | $168.02 | $936.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.19 / $78.19 / $496.52
| Professional | | $78.19 | $78.19 | $496.52 |