- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.27 / $148.88 / $249.22
| Professional | | $124.27 | $148.88 | $249.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.30 / $121.98 / $173.42
| Facility | | $95.30 | $121.98 | $173.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.20 / $103.40 / $171.50
| Professional | | $75.20 | $103.40 | $171.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.99 / $292.80 / $292.80
| Facility | | $110.99 | $292.80 | $292.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.45 / $361.01 / $361.01
| Professional | | $352.45 | $361.01 | $361.01 |