- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.23 / $186.41 / $186.41
| Professional | | $105.23 | $186.41 | $186.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.60 / $251.60 / $251.60
| Facility | | $251.60 | $251.60 | $251.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.91 / $175.73 / $349.49
| Professional | | $73.91 | $175.73 | $349.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.60 / $251.60 / $251.60
| Facility | | $251.60 | $251.60 | $251.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.91 / $175.73 / $349.49
| Professional | | $73.91 | $175.73 | $349.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.66 / $150.33 / $347.32
| Professional | | $65.66 | $150.33 | $347.32 |