- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.32 / $128.32 / $140.96
| Professional | | $128.32 | $128.32 | $140.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $460.47 / $636.04 / $1,043.88
| Facility | | $460.47 | $636.04 | $1,043.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.12 / $141.62 / $208.55
| Professional | | $116.12 | $141.62 | $208.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.82 / $200.55 / $258.68
| Professional | | $136.82 | $200.55 | $258.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.19 / $156.43 / $293.49
| Professional | | $135.19 | $156.43 | $293.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.32 / $128.32 / $181.60
| Professional | | $128.32 | $128.32 | $181.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $204.64 / $236.57
| Professional | | $127.45 | $204.64 | $236.57 |