- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.12 / $199.89 / $285.08
| Professional | | $126.12 | $199.89 | $285.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $178.75 / $246.90 / $405.22
| Facility | | $178.75 | $246.90 | $405.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.98 / $211.28 / $293.51
| Professional | | $120.98 | $211.28 | $293.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.33 / $145.18 / $208.42
| Professional | | $99.33 | $145.18 | $208.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.79 / $133.06 / $249.64
| Professional | | $87.79 | $133.06 | $249.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.88 / $142.41 / $285.08
| Professional | | $87.88 | $142.41 | $285.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.72 / $488.38 / $601.09
| Professional | | $156.72 | $488.38 | $601.09 |