- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.51 / $279.33 / $335.98
| Professional | | $247.51 | $279.33 | $335.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $800.92 / $1,081.75 / $1,280.66
| Facility | | $800.92 | $1,081.75 | $1,280.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.05 / $297.70 / $497.88
| Professional | | $253.05 | $297.70 | $497.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $290.63 / $290.63 / $327.66
| Facility | | $290.63 | $290.63 | $327.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.16 / $290.63 / $290.63
| Professional | | $212.16 | $290.63 | $290.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.69 / $282.61 / $471.02
| Professional | | $210.69 | $282.61 | $471.02 |