- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.12 / $344.89 / $369.55
| Professional | | $237.12 | $344.89 | $369.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $770.39 / $1,022.02 / $1,209.96
| Facility | | $770.39 | $1,022.02 | $1,209.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.85 / $323.35 / $484.00
| Professional | | $274.85 | $323.35 | $484.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.73 / $375.73 / $383.66
| Facility | | $375.73 | $375.73 | $383.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.27 / $375.73 / $383.66
| Professional | | $274.27 | $375.73 | $383.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.06 / $305.64 / $445.02
| Professional | | $209.06 | $305.64 | $445.02 |