- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.10 / $123.67 / $128.01
| Professional | | $91.10 | $123.67 | $128.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $294.80 / $398.17 / $471.38
| Facility | | $294.80 | $398.17 | $471.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.76 / $136.19 / $188.55
| Professional | | $115.76 | $136.19 | $188.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.60 / $175.58 / $175.58
| Facility | | $120.60 | $175.58 | $175.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.16 / $175.58 / $175.58
| Professional | | $128.16 | $175.58 | $175.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.91 / $128.22 / $173.37
| Professional | | $97.91 | $128.22 | $173.37 |