- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.16 / $122.75 / $187.56
| Professional | | $113.16 | $122.75 | $187.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.08 / $111.75 / $216.29
| Professional | | $105.08 | $111.75 | $216.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.14 / $146.46 / $247.17
| Professional | | $106.14 | $146.46 | $247.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.17 / $191.00 / $315.18
| Facility | | $118.17 | $191.00 | $315.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.16 / $151.16 / $278.52
| Professional | | $115.16 | $151.16 | $278.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $283.52 / $321.38 / $1,564.67
| Facility | | $283.52 | $321.38 | $1,564.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.68 / $1,165.68 / $1,165.68
| Professional | | $1,165.68 | $1,165.68 | $1,165.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.59 / $133.63 / $227.36
| Professional | | $103.59 | $133.63 | $227.36 |