- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $131.83 / $549.54
| Professional | | $102.33 | $131.83 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $660.69 / $660.69
| Facility | | $524.81 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $173.78 / $218.78
| Professional | | $120.23 | $173.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $208.93 / $309.03
| Professional | | $154.88 | $208.93 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $186.21 / $354.81
| Professional | | $158.49 | $186.21 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $158.49 / $549.54
| Professional | | $125.89 | $158.49 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $234.42 / $323.59
| Professional | | $144.54 | $234.42 | $323.59 |