- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.20 / $162.16 / $162.16
| Professional | | $105.20 | $162.16 | $162.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $214.15 / $277.45 / $514.30
| Facility | | $214.15 | $277.45 | $514.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.08 / $159.08 / $180.77
| Professional | | $159.08 | $159.08 | $180.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.81 / $170.64 / $176.97
| Facility | | $168.81 | $170.64 | $176.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.57 / $124.57 / $170.64
| Professional | | $124.57 | $124.57 | $170.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.94 / $194.94 / $194.94
| Professional | | $194.94 | $194.94 | $194.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.58 / $162.16 / $162.16
| Professional | | $135.58 | $162.16 | $162.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.56 / $180.98 / $276.24
| Professional | | $92.56 | $180.98 | $276.24 |