- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.72 / $175.50 / $269.79
| Professional | | $106.72 | $175.50 | $269.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $552.33 / $552.33 / $707.36
| Facility | | $552.33 | $552.33 | $707.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.21 / $267.54 / $912.06
| Professional | | $141.21 | $267.54 | $912.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.35 / $271.95 / $912.06
| Professional | | $153.35 | $271.95 | $912.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.90 / $300.48 / $873.52
| Professional | | $205.90 | $300.48 | $873.52 |