- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.04 / $141.83 / $141.83
| Professional | | $106.04 | $141.83 | $141.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.60 / $246.60 / $246.60
| Facility | | $246.60 | $246.60 | $246.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.08 / $202.08 / $218.25
| Professional | | $202.08 | $202.08 | $218.25 |
- 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 / $196.56
| Professional | | $141.36 | $166.31 | $196.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.06 / $553.16 / $701.12
| Professional | | $197.06 | $553.16 | $701.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.23 / $146.02 / $228.79
| Professional | | $87.23 | $146.02 | $228.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.30 / $250.73 / $319.12
| Professional | | $226.30 | $250.73 | $319.12 |