- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.51 / $258.92 / $1,381.05
| Professional | | $227.51 | $258.92 | $1,381.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $404.87 / $404.87 / $404.87
| Facility | | $404.87 | $404.87 | $404.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.52 / $404.87 / $760.16
| Professional | | $259.52 | $404.87 | $760.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $201.64 / $261.20 / $520.49
| Facility | | $201.64 | $261.20 | $520.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.13 / $412.49 / $687.35
| Professional | | $268.13 | $412.49 | $687.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.59 / $446.04 / $566.88
| Professional | | $377.59 | $446.04 | $566.88 |