- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.31 / $336.32 / $362.85
| Professional | | $267.31 | $336.32 | $362.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $864.98 / $1,168.29 / $1,383.12
| Facility | | $864.98 | $1,168.29 | $1,383.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.52 / $321.52 / $537.71
| Professional | | $321.52 | $321.52 | $537.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $405.51 / $405.51 / $405.51
| Facility | | $405.51 | $405.51 | $405.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.02 / $405.51 / $405.51
| Professional | | $296.02 | $405.51 | $405.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.86 / $349.39 / $508.69
| Professional | | $275.86 | $349.39 | $508.69 |