- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.83 / $209.47 / $350.63
| Professional | | $174.83 | $209.47 | $350.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.42 / $160.99 / $236.76
| Facility | | $124.42 | $160.99 | $236.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.00 / $136.69 / $241.90
| Professional | | $103.00 | $136.69 | $241.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.16 / $384.75 / $384.75
| Facility | | $151.16 | $384.75 | $384.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.34 / $511.57 / $511.57
| Professional | | $489.34 | $511.57 | $511.57 |