- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.38 / $203.37 / $225.36
| Professional | | $192.38 | $203.37 | $225.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.32 / $323.69 / $338.04
| Facility | | $291.32 | $323.69 | $338.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.15 / $364.15 / $364.15
| Professional | | $364.15 | $364.15 | $364.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.97 / $812.97 / $812.97
| Facility | | $812.97 | $812.97 | $812.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.74 / $274.83 / $439.73
| Professional | | $135.74 | $274.83 | $439.73 |