- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.74 / $294.20 / $294.20
| Professional | | $256.74 | $294.20 | $294.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $757.93 / $1,046.93 / $1,718.23
| Facility | | $757.93 | $1,046.93 | $1,718.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.25 / $308.54 / $462.26
| Professional | | $262.25 | $308.54 | $462.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.39 / $408.83 / $555.64
| Professional | | $306.39 | $408.83 | $555.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.31 / $340.52 / $638.89
| Professional | | $294.31 | $340.52 | $638.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.74 / $294.20 / $393.42
| Professional | | $256.74 | $294.20 | $393.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.45 / $352.57 / $496.47
| Professional | | $205.45 | $352.57 | $496.47 |