- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.37 / $248.84 / $327.64
| Professional | | $241.37 | $248.84 | $327.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $781.04 / $1,054.86 / $1,248.84
| Facility | | $781.04 | $1,054.86 | $1,248.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.70 / $360.82 / $499.55
| Professional | | $306.70 | $360.82 | $499.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.52 / $274.52 / $319.52
| Facility | | $274.52 | $274.52 | $319.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.41 / $274.52 / $274.52
| Professional | | $200.41 | $274.52 | $274.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.08 / $311.05 / $459.32
| Professional | | $249.08 | $311.05 | $459.32 |