- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.87 / $155.40 / $203.09
| Professional | | $97.87 | $155.40 | $203.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.14 / $176.14 / $176.14
| Facility | | $176.14 | $176.14 | $176.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.14 / $176.93 / $304.97
| Professional | | $176.14 | $176.93 | $304.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.57 / $292.50 / $330.80
| Facility | | $108.57 | $292.50 | $330.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.21 / $193.48 / $304.97
| Professional | | $113.21 | $193.48 | $304.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.98 / $305.02 / $518.92
| Professional | | $242.98 | $305.02 | $518.92 |