- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.54 / $177.39 / $241.66
| Professional | | $110.54 | $177.39 | $241.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.96 / $202.08 / $264.88
| Professional | | $174.96 | $202.08 | $264.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.31 / $166.31 / $214.71
| Facility | | $166.31 | $166.31 | $214.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.36 / $166.31 / $196.56
| Professional | | $141.36 | $166.31 | $196.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.40 / $264.92 / $1,193.68
| Facility | | $123.40 | $264.92 | $1,193.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.12 / $168.17 / $300.55
| Professional | | $120.12 | $168.17 | $300.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.12 / $148.94 / $303.23
| Professional | | $120.12 | $148.94 | $303.23 |