- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.30 / $111.83 / $576.88
| Professional | | $96.30 | $111.83 | $576.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.62 / $175.62 / $175.62
| Facility | | $175.62 | $175.62 | $175.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.86 / $175.62 / $325.19
| Professional | | $109.86 | $175.62 | $325.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.31 / $164.02 / $210.08
| Facility | | $108.31 | $164.02 | $210.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.72 / $179.55 / $299.20
| Professional | | $116.72 | $179.55 | $299.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.65 / $192.64 / $246.69
| Professional | | $155.65 | $192.64 | $246.69 |