- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.13 / $137.38 / $139.68
| Professional | | $114.13 | $137.38 | $139.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.08 / $139.44 / $139.44
| Professional | | $130.08 | $139.44 | $139.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.47 / $114.47 / $150.25
| Facility | | $114.47 | $114.47 | $150.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.30 / $114.47 / $150.25
| Professional | | $97.30 | $114.47 | $150.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.39 / $106.20 / $150.31
| Professional | | $96.39 | $106.20 | $150.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.80 / $148.80 / $148.80
| Professional | | $148.80 | $148.80 | $148.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.01 / $105.80 / $161.10
| Professional | | $83.01 | $105.80 | $161.10 |