- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.27 / $162.57 / $199.03
| Professional | | $115.27 | $162.57 | $199.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $491.39 / $491.39 / $530.87
| Facility | | $491.39 | $491.39 | $530.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.47 / $214.62 / $328.22
| Professional | | $142.47 | $214.62 | $328.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.47 / $214.62 / $364.05
| Professional | | $142.47 | $214.62 | $364.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.05 / $261.08 / $606.75
| Professional | | $246.05 | $261.08 | $606.75 |