- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.91 / $180.61 / $198.07
| Professional | | $145.91 | $180.61 | $198.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $472.17 / $637.74 / $755.01
| Facility | | $472.17 | $637.74 | $755.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.41 / $218.13 / $302.01
| Professional | | $185.41 | $218.13 | $302.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.15 / $225.68 / $225.68
| Facility | | $193.15 | $225.68 | $225.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.75 / $225.68 / $225.68
| Professional | | $164.75 | $225.68 | $225.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.58 / $190.73 / $277.69
| Professional | | $150.58 | $190.73 | $277.69 |