- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.30 / $200.45 / $335.53
| Professional | | $167.30 | $200.45 | $335.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.34 / $202.28 / $361.21
| Facility | | $30.34 | $202.28 | $361.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.60 / $146.60 / $185.10
| Professional | | $146.60 | $146.60 | $185.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $625.83 / $625.83
| Facility | | $371.54 | $625.83 | $625.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $921.00 / $921.00 / $921.00
| Professional | | $921.00 | $921.00 | $921.00 |