- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.16 / $160.81 / $160.81
| Professional | | $137.16 | $160.81 | $160.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $417.56 / $576.78 / $946.62
| Facility | | $417.56 | $576.78 | $946.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.16 / $180.20 / $238.33
| Professional | | $153.16 | $180.20 | $238.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.80 / $148.80 / $148.80
| Facility | | $148.80 | $148.80 | $148.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.57 / $187.13 / $295.38
| Professional | | $140.57 | $187.13 | $295.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.12 / $190.77 / $292.64
| Professional | | $148.12 | $190.77 | $292.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.16 / $160.81 / $160.81
| Professional | | $137.16 | $160.81 | $160.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.91 / $186.80 / $307.41
| Professional | | $133.91 | $186.80 | $307.41 |