- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.54 / $327.83 / $576.91
| Professional | | $285.54 | $327.83 | $576.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $503.19 / $503.19 / $503.19
| Facility | | $503.19 | $503.19 | $503.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.42 / $503.19 / $577.33
| Professional | | $359.42 | $503.19 | $577.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.10 / $561.60 / $595.17
| Facility | | $281.10 | $561.60 | $595.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.22 / $500.92 / $703.55
| Professional | | $331.22 | $500.92 | $703.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $468.12 / $577.67 / $1,012.86
| Professional | | $468.12 | $577.67 | $1,012.86 |