- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.63 / $137.05 / $151.86
| Professional | | $129.63 | $137.05 | $151.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.32 / $218.13 / $227.80
| Facility | | $196.32 | $218.13 | $227.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.39 / $245.39 / $245.39
| Professional | | $245.39 | $245.39 | $245.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $547.82 / $547.82 / $547.82
| Facility | | $547.82 | $547.82 | $547.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.78 / $111.12 / $267.11
| Professional | | $77.78 | $111.12 | $267.11 |