- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.75 / $148.74 / $195.09
| Professional | | $132.75 | $148.74 | $195.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.42 / $26.42 / $26.42
| Facility | | $26.42 | $26.42 | $26.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.55 / $19.55 / $19.55
| Professional | | $19.55 | $19.55 | $19.55 |
- 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 / $153.77
| Professional | | $18.44 | $153.77 | $153.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.30 / $90.27 / $168.23
| Professional | | $70.30 | $90.27 | $168.23 |