- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.31 / $279.32 / $517.36
| Professional | | $194.31 | $279.32 | $517.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.81 / $407.81 / $407.81
| Facility | | $407.81 | $407.81 | $407.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.64 / $407.81 / $652.50
| Professional | | $346.64 | $407.81 | $652.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $484.50 / $484.50 / $484.50
| Professional | | $484.50 | $484.50 | $484.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.60 / $389.60 / $389.60
| Professional | | $389.60 | $389.60 | $389.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.57 / $325.43 / $382.82
| Professional | | $251.57 | $325.43 | $382.82 |