- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.22 / $346.44 / $372.49
| Professional | | $255.22 | $346.44 | $372.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $825.85 / $1,115.42 / $1,320.52
| Facility | | $825.85 | $1,115.42 | $1,320.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.97 / $306.97 / $513.38
| Professional | | $306.97 | $306.97 | $513.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $337.86 / $503.81 / $503.81
| Facility | | $337.86 | $503.81 | $503.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.78 / $367.78 / $367.78
| Professional | | $367.78 | $367.78 | $367.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.30 / $372.27 / $485.68
| Professional | | $274.30 | $372.27 | $485.68 |