- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.75 / $152.22 / $173.46
| Professional | | $132.75 | $152.22 | $173.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $138.53 / $138.53
| Professional | | $127.45 | $138.53 | $138.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.77 / $153.77 / $153.77
| Facility | | $153.77 | $153.77 | $153.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.44 / $153.77 / $288.75
| Professional | | $18.44 | $153.77 | $288.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.95 / $99.75 / $166.97
| Professional | | $67.95 | $99.75 | $166.97 |