- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.17 / $126.11 / $165.84
| Professional | | $122.17 | $126.11 | $165.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $395.33 / $533.92 / $632.11
| Facility | | $395.33 | $533.92 | $632.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.44 / $157.44 / $252.85
| Professional | | $157.44 | $157.44 | $252.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.66 / $139.66 / $161.74
| Facility | | $139.66 | $139.66 | $161.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.95 / $139.66 / $139.66
| Professional | | $101.95 | $139.66 | $139.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.11 / $139.49 / $232.49
| Professional | | $95.11 | $139.49 | $232.49 |