- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.90 / $137.38 / $171.05
| Professional | | $119.90 | $137.38 | $171.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.87 / $17.48 / $17.48
| Professional | | $14.87 | $17.48 | $17.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.50 / $240.50 / $240.50
| Facility | | $240.50 | $240.50 | $240.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.43 / $240.50 / $240.50
| Professional | | $204.43 | $240.50 | $240.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.18 / $172.86 / $288.10
| Professional | | $106.18 | $172.86 | $288.10 |