- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.38 / $249.38 / $311.72
| Professional | | $249.38 | $249.38 | $311.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.30 / $1,288.30 / $1,288.30
| Facility | | $1,288.30 | $1,288.30 | $1,288.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.51 / $1,471.51 / $1,471.51
| Professional | | $1,471.51 | $1,471.51 | $1,471.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.96 / $269.04 / $510.18
| Facility | | $248.96 | $269.04 | $510.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.00 / $297.51 / $510.18
| Professional | | $243.00 | $297.51 | $510.18 |