- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.66 / $253.27 / $253.27
| Professional | | $202.66 | $253.27 | $253.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.31 / $282.61 / $441.66
| Professional | | $210.31 | $282.61 | $441.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.68 / $240.68 / $456.00
| Facility | | $240.68 | $240.68 | $456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.72 / $311.79 / $473.19
| Professional | | $204.72 | $311.79 | $473.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.58 / $308.56 / $482.85
| Professional | | $239.58 | $308.56 | $482.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.66 / $253.27 / $504.70
| Professional | | $202.66 | $253.27 | $504.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.82 / $285.18 / $457.92
| Professional | | $202.82 | $285.18 | $457.92 |