- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.18 / $202.21 / $209.30
| Professional | | $159.18 | $202.21 | $209.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.58 / $206.74 / $206.74
| Professional | | $164.58 | $206.74 | $206.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.27 / $174.27 / $174.27
| Facility | | $174.27 | $174.27 | $174.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.13 / $174.27 / $174.27
| Professional | | $148.13 | $174.27 | $174.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.23 / $139.07 / $196.83
| Professional | | $126.23 | $139.07 | $196.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.28 / $162.28 / $162.28
| Professional | | $162.28 | $162.28 | $162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.52 / $129.90 / $175.70
| Professional | | $90.52 | $129.90 | $175.70 |