- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.10 / $163.06 / $272.95
| Professional | | $136.10 | $163.06 | $272.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.08 / $126.61 / $184.23
| Facility | | $98.08 | $126.61 | $184.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.50 / $110.60 / $187.90
| Professional | | $80.50 | $110.60 | $187.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.35 / $303.87 / $303.87
| Facility | | $118.35 | $303.87 | $303.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.57 / $396.65 / $396.65
| Professional | | $381.57 | $396.65 | $396.65 |