- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.38 / $206.42 / $255.47
| Professional | | $204.38 | $206.42 | $255.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $276.43 / $330.51 / $749.48
| Facility | | $276.43 | $330.51 | $749.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.73 / $1,080.20 / $1,080.20
| Professional | | $410.73 | $1,080.20 | $1,080.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $276.43 / $276.43 / $330.51
| Facility | | $276.43 | $276.43 | $330.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.43 / $330.51 / $431.67
| Professional | | $276.43 | $330.51 | $431.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.80 / $228.80 / $228.80
| Professional | | $228.80 | $228.80 | $228.80 |