- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.66 / $211.12 / $320.37
| Professional | | $143.66 | $211.12 | $320.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $382.10 / $946.16 / $1,109.17
| Facility | | $382.10 | $946.16 | $1,109.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.58 / $1,172.58 / $1,594.65
| Professional | | $1,172.58 | $1,172.58 | $1,594.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.10 / $192.10 / $195.44
| Facility | | $192.10 | $192.10 | $195.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.83 / $232.65 / $425.82
| Professional | | $160.83 | $232.65 | $425.82 |