- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $199.53 / $245.47
| Professional | | $165.96 | $199.53 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $489.78 / $489.78
| Facility | | $131.83 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $229.09 / $436.52
| Professional | | $91.20 | $229.09 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $131.83 / $141.25
| Professional | | $131.83 | $131.83 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $165.96 / $165.96
| Professional | | $141.25 | $165.96 | $165.96 |