- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.24 / $147.18 / $289.16
| Professional | | $113.24 | $147.18 | $289.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $535.98 / $535.98 / $686.43
| Facility | | $535.98 | $535.98 | $686.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.81 / $215.24 / $554.47
| Professional | | $152.81 | $215.24 | $554.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.33 / $221.89 / $554.47
| Professional | | $159.33 | $221.89 | $554.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.86 / $216.85 / $693.63
| Professional | | $176.86 | $216.85 | $693.63 |