- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.78 / $153.90 / $198.42
| Professional | | $135.78 | $153.90 | $198.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $325.47 / $361.63 / $496.75
| Facility | | $325.47 | $361.63 | $496.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.59 / $156.79 / $156.79
| Professional | | $117.59 | $156.79 | $156.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $221.93
| Professional | | $141.06 | $141.06 | $221.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.86 / $241.40 / $306.32
| Professional | | $185.86 | $241.40 | $306.32 |