- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.20 / $180.20 / $198.21
| Professional | | $180.20 | $180.20 | $198.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.81 / $203.81 / $203.81
| Facility | | $203.81 | $203.81 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.81 / $203.81 / $203.81
| Professional | | $203.81 | $203.81 | $203.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.88 / $180.20 / $257.69
| Facility | | $157.88 | $180.20 | $257.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.51 / $138.51 / $138.51
| Professional | | $138.51 | $138.51 | $138.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.68 / $134.68 / $165.29
| Facility | | $134.68 | $134.68 | $165.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.20 / $233.20 / $238.50
| Professional | | $233.20 | $233.20 | $238.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.63 / $218.36 / $254.76
| Professional | | $205.63 | $218.36 | $254.76 |