- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.77 / $230.25 / $230.25
| Professional | | $200.77 | $230.25 | $230.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $643.54 / $888.92 / $1,458.90
| Facility | | $643.54 | $888.92 | $1,458.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.48 / $237.49 / $354.80
| Professional | | $200.48 | $237.49 | $354.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.35 / $325.67 / $424.76
| Professional | | $235.35 | $325.67 | $424.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.71 / $262.30 / $492.14
| Professional | | $226.71 | $262.30 | $492.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.77 / $230.25 / $302.14
| Professional | | $200.77 | $230.25 | $302.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.70 / $277.82 / $381.34
| Professional | | $166.70 | $277.82 | $381.34 |