- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.40 / $84.51 / $162.87
| Professional | | $77.40 | $84.51 | $162.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.10 / $164.10 / $164.10
| Professional | | $164.10 | $164.10 | $164.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.30 / $120.30 / $236.68
| Facility | | $120.30 | $120.30 | $236.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.30 / $120.30 / $120.30
| Professional | | $120.30 | $120.30 | $120.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.98 / $93.31 / $109.63
| Professional | | $84.98 | $93.31 | $109.63 |