- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.85 / $130.78 / $172.19
| Professional | | $126.85 | $130.78 | $172.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $410.47 / $554.40 / $656.35
| Facility | | $410.47 | $554.40 | $656.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.19 / $189.63 / $262.55
| Professional | | $161.19 | $189.63 | $262.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.85 / $140.85 / $167.93
| Facility | | $140.85 | $140.85 | $167.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.82 / $102.82 / $102.82
| Professional | | $102.82 | $102.82 | $102.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.91 / $163.24 / $241.40
| Professional | | $130.91 | $163.24 | $241.40 |