- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $151.36 / $208.93
| Professional | | $112.20 | $151.36 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $151.36 / $251.19
| Professional | | $114.82 | $151.36 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $181.97 / $269.15
| Professional | | $120.23 | $181.97 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $204.17 / $331.13
| Professional | | $134.90 | $204.17 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $162.18 / $288.40
| Facility | | $114.82 | $162.18 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $269.15 / $1,047.13
| Professional | | $151.36 | $269.15 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $173.78 / $281.84
| Professional | | $117.49 | $173.78 | $281.84 |