- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.11 / $117.73 / $704.87
| Professional | | $110.11 | $117.73 | $704.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.86 / $417.72 / $805.75
| Facility | | $200.86 | $417.72 | $805.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.62 / $200.86 / $319.47
| Professional | | $130.62 | $200.86 | $319.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.75 / $201.78 / $417.72
| Facility | | $129.75 | $201.78 | $417.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.58 / $205.97 / $320.95
| Professional | | $123.58 | $205.97 | $320.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.94 / $223.29 / $263.04
| Professional | | $180.94 | $223.29 | $263.04 |