- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.36 / $169.24 / $299.97
| Professional | | $103.36 | $169.24 | $299.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $505.03 / $803.22 / $1,028.69
| Facility | | $505.03 | $803.22 | $1,028.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.19 / $258.52 / $670.40
| Professional | | $159.19 | $258.52 | $670.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.01 / $271.74 / $670.40
| Professional | | $161.01 | $271.74 | $670.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.68 / $267.89 / $806.65
| Professional | | $198.68 | $267.89 | $806.65 |