- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.75 / $401.29 / $501.62
| Professional | | $314.75 | $401.29 | $501.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $403.25 / $403.25 / $677.34
| Facility | | $403.25 | $403.25 | $677.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.00 / $1,386.51 / $1,386.51
| Professional | | $1,204.00 | $1,386.51 | $1,386.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.19 / $299.00 / $307.95
| Facility | | $245.19 | $299.00 | $307.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.00 / $307.95 / $418.37
| Professional | | $242.00 | $307.95 | $418.37 |