- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.22 / $140.22 / $157.43
| Professional | | $140.22 | $140.22 | $157.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.82 / $329.88 / $541.40
| Facility | | $238.82 | $329.88 | $541.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.01 / $163.29 / $223.18
| Professional | | $126.01 | $163.29 | $223.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.83 / $197.16 / $281.39
| Professional | | $148.83 | $197.16 | $281.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.51 / $168.36 / $315.87
| Professional | | $145.51 | $168.36 | $315.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.22 / $140.22 / $157.43
| Professional | | $140.22 | $140.22 | $157.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.39 / $206.69 / $311.77
| Professional | | $120.39 | $206.69 | $311.77 |