- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.39 / $130.77 / $130.77
| Professional | | $78.39 | $130.77 | $130.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.51 / $115.51 / $136.50
| Facility | | $115.51 | $115.51 | $136.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.16 / $115.51 / $205.50
| Professional | | $100.16 | $115.51 | $205.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.67 / $130.77 / $226.91
| Facility | | $75.67 | $130.77 | $226.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.55 / $331.55 / $331.55
| Professional | | $331.55 | $331.55 | $331.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.59 / $107.65 / $206.03
| Professional | | $75.59 | $107.65 | $206.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.86 / $829.11 / $829.11
| Facility | | $207.86 | $829.11 | $829.11 |