- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.07 / $243.38 / $320.44
| Professional | | $236.07 | $243.38 | $320.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $763.88 / $1,031.72 / $1,221.44
| Facility | | $763.88 | $1,031.72 | $1,221.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.34 / $283.93 / $474.86
| Professional | | $241.34 | $283.93 | $474.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.20 / $253.20 / $312.50
| Facility | | $253.20 | $253.20 | $312.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.84 / $253.20 / $253.20
| Professional | | $184.84 | $253.20 | $253.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.55 / $269.54 / $449.24
| Professional | | $183.55 | $269.54 | $449.24 |