- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.13 / $106.13 / $132.66
| Professional | | $106.13 | $106.13 | $132.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $298.45 / $420.38 / $420.38
| Facility | | $298.45 | $420.38 | $420.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.55 / $583.55 / $583.55
| Professional | | $583.55 | $583.55 | $583.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.60 / $149.82 / $172.18
| Facility | | $115.60 | $149.82 | $172.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.60 / $167.71 / $234.37
| Professional | | $115.60 | $167.71 | $234.37 |