- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.58 / $379.58 / $422.95
| Professional | | $311.58 | $379.58 | $422.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,008.26 / $1,361.80 / $1,612.21
| Facility | | $1,008.26 | $1,361.80 | $1,612.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.31 / $401.54 / $644.89
| Professional | | $341.31 | $401.54 | $644.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $394.91 / $394.91 / $412.48
| Facility | | $394.91 | $394.91 | $412.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.27 / $394.90 / $394.91
| Professional | | $288.27 | $394.90 | $394.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.57 / $407.26 / $592.95
| Professional | | $278.57 | $407.26 | $592.95 |