- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.74 / $146.86 / $151.25
| Professional | | $119.74 | $146.86 | $151.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.44 / $153.44 / $206.74
| Professional | | $153.44 | $153.44 | $206.74 |
- 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
- $19.86 / $174.27 / $307.50
| Professional | | $19.86 | $174.27 | $307.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.38 / $28.38 / $28.38
| Professional | | $28.38 | $28.38 | $28.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.77 / $116.71 / $194.52
| Professional | | $71.77 | $116.71 | $194.52 |