- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.50 / $294.22 / $317.44
| Professional | | $162.50 | $294.22 | $317.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $756.72 / $1,022.02 / $1,209.96
| Facility | | $756.72 | $1,022.02 | $1,209.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.14 / $349.58 / $484.00
| Professional | | $297.14 | $349.58 | $484.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $321.89 / $336.03 / $336.03
| Facility | | $321.89 | $336.03 | $336.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $245.30
| Professional | | $245.30 | $245.30 | $245.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.06 / $286.10 / $445.02
| Professional | | $209.06 | $286.10 | $445.02 |