- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.56 / $155.99 / $190.89
| Professional | | $127.56 | $155.99 | $190.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.20 / $411.60 / $487.28
| Facility | | $317.20 | $411.60 | $487.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.83 / $176.27 / $220.03
| Professional | | $149.83 | $176.27 | $220.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.59 / $188.67 / $293.85
| Professional | | $185.59 | $188.67 | $293.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.51 / $228.09 / $284.00
| Professional | | $172.51 | $228.09 | $284.00 |