- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.36 / $171.52 / $198.19
| Professional | | $126.36 | $171.52 | $198.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $408.90 / $552.25 / $653.79
| Facility | | $408.90 | $552.25 | $653.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.41 / $162.84 / $261.52
| Professional | | $138.41 | $162.84 | $261.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.28 / $180.71 / $180.71
| Facility | | $167.28 | $180.71 | $180.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.91 / $180.71 / $180.71
| Professional | | $131.91 | $180.71 | $180.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.28 / $154.59 / $240.46
| Professional | | $122.28 | $154.59 | $240.46 |