- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.31 / $118.52 / $131.87
| Professional | | $87.31 | $118.52 | $131.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $282.52 / $381.60 / $451.77
| Facility | | $282.52 | $381.60 | $451.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.26 / $105.01 / $175.64
| Professional | | $89.26 | $105.01 | $175.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.59 / $172.35 / $172.35
| Facility | | $115.59 | $172.35 | $172.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.82 / $172.35 / $172.35
| Professional | | $125.82 | $172.35 | $172.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.74 / $131.74 / $131.74
| Facility | | $131.74 | $131.74 | $131.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.10 / $127.38 / $166.15
| Professional | | $90.10 | $127.38 | $166.15 |