- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.75 / $172.52 / $203.44
| Professional | | $162.75 | $172.52 | $203.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,097.59 / $1,097.59 / $1,097.59
| Facility | | $1,097.59 | $1,097.59 | $1,097.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.83 / $346.88 / $2,848.34
| Professional | | $330.83 | $346.88 | $2,848.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.42 / $201.87 / $201.87
| Facility | | $194.42 | $201.87 | $201.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.42 / $260.08 / $346.88
| Professional | | $194.42 | $260.08 | $346.88 |