- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.41 / $608.53 / $608.53
| Professional | | $114.41 | $608.53 | $608.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.74 / $176.50 / $496.81
| Facility | | $130.74 | $176.50 | $496.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.19 / $166.45 / $311.38
| Professional | | $147.19 | $166.45 | $311.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.74 / $176.50 / $496.81
| Facility | | $130.74 | $176.50 | $496.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.31 / $140.69 / $191.78
| Professional | | $99.31 | $140.69 | $191.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.35 / $103.43 / $187.61
| Professional | | $87.35 | $103.43 | $187.61 |