- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.98 / $128.38 / $132.22
| Professional | | $104.98 | $128.38 | $132.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.13 / $153.63 / $161.11
| Professional | | $134.13 | $153.63 | $161.11 |
- 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
- $114.26 / $134.41 / $253.88
| Professional | | $114.26 | $134.41 | $253.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.14 / $164.14 / $164.14
| Professional | | $164.14 | $164.14 | $164.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.66 / $92.80 / $154.66
| Professional | | $72.66 | $92.80 | $154.66 |