- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.66 / $138.47 / $196.19
| Professional | | $130.66 | $138.47 | $196.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.47 / $268.86 / $302.47
| Facility | | $202.47 | $268.86 | $302.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.27 / $246.46 / $519.47
| Professional | | $211.27 | $246.46 | $519.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $237.59 / $237.59 / $237.59
| Facility | | $237.59 | $237.59 | $237.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.51 / $84.51 / $84.51
| Professional | | $84.51 | $84.51 | $84.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.83 / $111.78 / $187.13
| Professional | | $87.83 | $111.78 | $187.13 |