- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.42 / $216.64 / $259.56
| Professional | | $206.42 | $216.64 | $259.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $378.57 / $712.44 / $749.48
| Facility | | $378.57 | $712.44 | $749.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.20 / $1,080.20 / $1,080.20
| Professional | | $1,080.20 | $1,080.20 | $1,080.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.50 / $235.50 / $235.50
| Professional | | $235.50 | $235.50 | $235.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.80 / $228.80 / $228.80
| Professional | | $228.80 | $228.80 | $228.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.62 / $202.18 / $294.83
| Professional | | $154.62 | $202.18 | $294.83 |