- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $218.78 / $380.19
| Professional | | $144.54 | $218.78 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $147.91 / $229.09
| Facility | | $102.33 | $147.91 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $407.38 / $575.44
| Professional | | $177.83 | $407.38 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $154.88 / $154.88
| Professional | | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $181.97 / $208.93
| Professional | | $120.23 | $181.97 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $263.03
| Professional | | $251.19 | $251.19 | $263.03 |