- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.20 / $262.08 / $345.07
| Professional | | $254.20 | $262.08 | $345.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $822.60 / $1,111.01 / $1,315.31
| Facility | | $822.60 | $1,111.01 | $1,315.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.45 / $327.60 / $526.13
| Professional | | $278.45 | $327.60 | $526.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $311.77 / $311.77 / $336.53
| Facility | | $311.77 | $311.77 | $336.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.60 / $311.77 / $311.77
| Professional | | $227.60 | $311.77 | $311.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.33 / $327.60 / $483.76
| Professional | | $262.33 | $327.60 | $483.76 |