- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.06 / $160.52 / $201.05
| Professional | | $140.06 | $160.52 | $201.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.67 / $253.67 / $253.67
| Facility | | $253.67 | $253.67 | $253.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.04 / $22.04 / $22.04
| Professional | | $22.04 | $22.04 | $22.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.27 / $174.27 / $252.36
| Facility | | $174.27 | $174.27 | $252.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.86 / $174.27 / $174.27
| Professional | | $19.86 | $174.27 | $174.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.81 / $99.91 / $232.16
| Professional | | $77.81 | $99.91 | $232.16 |