- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.83 / $326.89 / $352.70
| Professional | | $259.83 | $326.89 | $352.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $840.77 / $1,135.58 / $1,344.39
| Facility | | $840.77 | $1,135.58 | $1,344.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.61 / $334.84 / $537.76
| Professional | | $284.61 | $334.84 | $537.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $401.27 / $401.27 / $401.27
| Facility | | $401.27 | $401.27 | $401.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.93 / $401.27 / $401.27
| Professional | | $292.93 | $401.27 | $401.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.14 / $362.05 / $494.45
| Professional | | $268.14 | $362.05 | $494.45 |