- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.38 / $216.64 / $259.56
| Professional | | $204.38 | $216.64 | $259.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $749.48 / $749.48 / $749.48
| Facility | | $749.48 | $749.48 | $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 / $330.51 / $410.73
| Facility | | $276.43 | $330.51 | $410.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.51 / $400.73 / $431.67
| Professional | | $330.51 | $400.73 | $431.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.80 / $228.80 / $228.80
| Professional | | $228.80 | $228.80 | $228.80 |