- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $165.96 / $389.05
| Professional | | $120.23 | $165.96 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $501.19
| Facility | | $398.11 | $398.11 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $208.93 / $288.40
| Professional | | $138.04 | $208.93 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $199.53 / $257.04
| Professional | | $151.36 | $199.53 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $204.17 / $354.81
| Professional | | $162.18 | $204.17 | $354.81 |