- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.26 / $259.10 / $433.70
| Professional | | $216.26 | $259.10 | $433.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.00 / $46.00 / $46.00
| Professional | | $46.00 | $46.00 | $46.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.70 / $180.50 / $225.60
| Professional | | $168.70 | $180.50 | $225.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $313.74 / $477.72 / $477.72
| Facility | | $313.74 | $477.72 | $477.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.42 / $684.55 / $684.55
| Professional | | $625.42 | $684.55 | $684.55 |