- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.65 / $123.65 / $260.10
| Professional | | $123.65 | $123.65 | $260.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.88 / $183.65 / $340.44
| Facility | | $154.88 | $183.65 | $340.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.58 / $131.76 / $143.63
| Professional | | $130.58 | $131.76 | $143.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.51 / $115.51 / $182.59
| Facility | | $115.51 | $115.51 | $182.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.51 / $115.51 / $138.02
| Professional | | $115.51 | $115.51 | $138.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.36 / $127.36 / $127.36
| Professional | | $127.36 | $127.36 | $127.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.06 / $123.65 / $260.10
| Professional | | $72.06 | $123.65 | $260.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.82 / $111.81 / $261.77
| Professional | | $57.82 | $111.81 | $261.77 |