- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.53 / $242.10 / $242.10
| Professional | | $230.53 | $242.10 | $242.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.20 / $106.20 / $106.20
| Professional | | $106.20 | $106.20 | $106.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.98 / $166.40 / $271.80
| Professional | | $125.98 | $166.40 | $271.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.26 / $242.10 / $409.15
| Facility | | $227.26 | $242.10 | $409.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.40 / $269.32 / $285.72
| Professional | | $253.40 | $269.32 | $285.72 |