- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.13 / $131.84 / $139.50
| Professional | | $97.13 | $131.84 | $139.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $314.30 / $424.50 / $502.56
| Facility | | $314.30 | $424.50 | $502.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.82 / $116.82 / $195.38
| Professional | | $116.82 | $116.82 | $195.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.58 / $182.31 / $182.31
| Facility | | $128.58 | $182.31 | $182.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.09 / $182.31 / $182.31
| Professional | | $133.09 | $182.31 | $182.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.39 / $141.69 / $184.84
| Professional | | $104.39 | $141.69 | $184.84 |