- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.83 / $197.77 / $205.65
| Professional | | $166.83 | $197.77 | $205.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.25 / $202.08 / $202.08
| Professional | | $188.25 | $202.08 | $202.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.31 / $166.31 / $218.29
| Facility | | $166.31 | $166.31 | $218.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.36 / $166.31 / $218.29
| Professional | | $141.36 | $166.31 | $218.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.37 / $154.63 / $218.88
| Professional | | $140.37 | $154.63 | $218.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.10 / $233.10 / $233.10
| Professional | | $233.10 | $233.10 | $233.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.00 / $150.88 / $231.21
| Professional | | $120.00 | $150.88 | $231.21 |