- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.68 / $277.69 / $307.70
| Professional | | $262.68 | $277.69 | $307.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $397.77 / $441.97 / $461.56
| Facility | | $397.77 | $441.97 | $461.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.21 / $497.21 / $497.21
| Professional | | $497.21 | $497.21 | $497.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,109.06 / $1,109.06 / $1,109.06
| Facility | | $1,109.06 | $1,109.06 | $1,109.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.61 / $225.15 / $541.22
| Professional | | $157.61 | $225.15 | $541.22 |