- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.66 / $300.27 / $323.97
| Professional | | $238.66 | $300.27 | $323.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $772.28 / $1,043.08 / $1,234.89
| Facility | | $772.28 | $1,043.08 | $1,234.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.78 / $356.78 / $493.96
| Professional | | $356.78 | $356.78 | $493.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.03 / $362.03 / $362.03
| Facility | | $362.03 | $362.03 | $362.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.27 / $362.03 / $362.03
| Professional | | $264.27 | $362.03 | $362.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.30 / $332.57 / $454.18
| Professional | | $246.30 | $332.57 | $454.18 |