- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.06 / $138.36 / $146.50
| Professional | | $78.06 | $138.36 | $146.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.16 / $155.16 / $155.16
| Professional | | $155.16 | $155.16 | $155.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.50 / $151.50 / $151.50
| Professional | | $151.50 | $151.50 | $151.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.47 / $114.47 / $150.25
| Facility | | $114.47 | $114.47 | $150.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.47 / $114.47 / $202.50
| Professional | | $114.47 | $114.47 | $202.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.04 / $92.30 / $158.10
| Professional | | $58.04 | $92.30 | $158.10 |