- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.62 / $153.52 / $228.95
| Professional | | $107.62 | $153.52 | $228.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.33 / $260.33 / $260.33
| Facility | | $260.33 | $260.33 | $260.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.91 / $411.91 / $565.95
| Professional | | $411.91 | $411.91 | $565.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.00 / $40.52 / $171.80
| Facility | | $37.00 | $40.52 | $171.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.26 / $40.52 / $73.95
| Professional | | $32.26 | $40.52 | $73.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.60 / $44.10 / $122.45
| Professional | | $32.60 | $44.10 | $122.45 |