- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.66 / $138.57 / $231.96
| Professional | | $115.66 | $138.57 | $231.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.96 / $131.69 / $302.74
| Facility | | $108.96 | $131.69 | $302.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.70 / $114.70 / $174.10
| Professional | | $77.70 | $114.70 | $174.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.73 / $273.93 / $273.93
| Facility | | $168.73 | $273.93 | $273.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.00 / $426.00 / $426.00
| Professional | | $426.00 | $426.00 | $426.00 |