- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.81 / $117.57 / $221.68
| Professional | | $86.81 | $117.57 | $221.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.27 / $174.27 / $174.27
| Facility | | $174.27 | $174.27 | $174.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.13 / $174.27 / $307.50
| Professional | | $148.13 | $174.27 | $307.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.83 / $196.83 / $258.93
| Professional | | $196.83 | $196.83 | $258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.17 / $168.80 / $168.80
| Professional | | $19.17 | $168.80 | $168.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.58 / $138.88 / $248.46
| Professional | | $113.58 | $138.88 | $248.46 |