- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.07 / $170.54 / $172.46
| Professional | | $92.07 | $170.54 | $172.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.35 / $205.35 / $205.35
| Facility | | $205.35 | $205.35 | $205.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.01 / $148.01 / $148.01
| Professional | | $148.01 | $148.01 | $148.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.41 / $134.41 / $134.41
| Facility | | $134.41 | $134.41 | $134.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.41 / $134.41 / $253.88
| Professional | | $134.41 | $134.41 | $253.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.87 / $106.90 / $146.94
| Professional | | $61.87 | $106.90 | $146.94 |