- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.28 / $111.36 / $144.87
| Professional | | $73.28 | $111.36 | $144.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.16 / $155.16 / $155.16
| Professional | | $155.16 | $155.16 | $155.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.18 / $161.18 / $161.18
| Facility | | $161.18 | $161.18 | $161.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.18 / $161.18 / $161.18
| Professional | | $161.18 | $161.18 | $161.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.47 / $114.47 / $181.84
| Facility | | $114.47 | $114.47 | $181.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.30 / $114.47 / $150.25
| Professional | | $97.30 | $114.47 | $150.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.04 / $101.58 / $212.88
| Professional | | $58.04 | $101.58 | $212.88 |