- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.15 / $245.35 / $252.68
| Professional | | $210.15 | $245.35 | $252.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.33 / $256.33 / $307.75
| Professional | | $256.33 | $256.33 | $307.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.34 / $240.34 / $240.34
| Facility | | $240.34 | $240.34 | $240.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.42 / $240.34 / $483.75
| Professional | | $33.42 | $240.34 | $483.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.83 / $41.83 / $41.83
| Professional | | $41.83 | $41.83 | $41.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.37 / $208.08 / $260.36
| Professional | | $31.37 | $208.08 | $260.36 |