- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $251.19 / $512.86
| Professional | | $147.91 | $251.19 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.72 / $169.82 / $275.42
| Facility | | $97.72 | $169.82 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $575.44 / $575.44
| Professional | | $407.38 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $190.55 / $190.55
| Professional | | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $263.03 / $288.40
| Professional | | $251.19 | $263.03 | $288.40 |