- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.54 / $171.54 / $187.43
| Professional | | $171.54 | $171.54 | $187.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $336.90 / $769.23 / $896.28
| Facility | | $336.90 | $769.23 | $896.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.51 / $206.51 / $320.35
| Professional | | $206.51 | $206.51 | $320.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $856.65 / $964.52 / $1,695.57
| Facility | | $856.65 | $964.52 | $1,695.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.12 / $359.63 / $441.63
| Professional | | $215.12 | $359.63 | $441.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.29 / $173.73 / $287.93
| Professional | | $85.29 | $173.73 | $287.93 |