- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.26 / $134.75 / $190.05
| Professional | | $74.26 | $134.75 | $190.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $667.61 / $667.61 / $827.47
| Facility | | $667.61 | $667.61 | $827.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.79 / $141.82 / $380.10
| Professional | | $75.79 | $141.82 | $380.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.71 / $174.84 / $380.10
| Professional | | $102.71 | $174.84 | $380.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.15 / $181.54 / $527.74
| Professional | | $136.15 | $181.54 | $527.74 |