- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.94 / $175.68 / $215.55
| Professional | | $160.94 | $175.68 | $215.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.10 / $147.10 / $147.10
| Facility | | $147.10 | $147.10 | $147.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.38 / $125.04 / $151.51
| Professional | | $107.38 | $125.04 | $151.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.10 / $147.10 / $147.10
| Facility | | $147.10 | $147.10 | $147.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.38 / $125.04 / $151.51
| Professional | | $107.38 | $125.04 | $151.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.36 / $27.02 / $53.21
| Professional | | $8.36 | $27.02 | $53.21 |