- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.56 / $182.42 / $225.36
| Professional | | $172.56 | $182.42 | $225.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.32 / $323.69 / $338.04
| Facility | | $291.32 | $323.69 | $338.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.15 / $364.15 / $364.15
| Professional | | $364.15 | $364.15 | $364.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $729.40 / $729.40 / $729.40
| Facility | | $729.40 | $729.40 | $729.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.43 / $147.91 / $355.56
| Professional | | $115.43 | $147.91 | $355.56 |