- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.13 / $393.08 / $426.41
| Professional | | $314.13 | $393.08 | $426.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,016.50 / $1,372.91 / $1,625.36
| Facility | | $1,016.50 | $1,372.91 | $1,625.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.83 / $377.83 / $631.89
| Professional | | $377.83 | $377.83 | $631.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $415.85 / $484.42 / $484.42
| Facility | | $415.85 | $484.42 | $484.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.63 / $484.42 / $484.42
| Professional | | $353.63 | $484.42 | $484.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.51 / $410.59 / $597.79
| Professional | | $326.51 | $410.59 | $597.79 |