- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $204.17 / $331.13
| Professional | | $144.54 | $204.17 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $575.44
| Facility | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $257.04 / $616.60
| Professional | | $190.55 | $257.04 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $239.88 / $645.65
| Professional | | $169.82 | $239.88 | $645.65 |