- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.13 / $112.49 / $132.66
| Professional | | $106.13 | $112.49 | $132.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.18 / $298.45 / $420.38
| Facility | | $172.18 | $298.45 | $420.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.18 / $583.55 / $583.55
| Professional | | $172.18 | $583.55 | $583.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.60 / $149.82 / $172.18
| Facility | | $115.60 | $149.82 | $172.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.79 / $172.18 / $226.32
| Professional | | $135.79 | $172.18 | $226.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.13 / $160.00 / $205.51
| Professional | | $115.13 | $160.00 | $205.51 |