- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.04 / $136.28 / $182.52
| Professional | | $106.04 | $136.28 | $182.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.75 / $213.75 / $213.75
| Professional | | $213.75 | $213.75 | $213.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.31 / $166.31 / $218.29
| Facility | | $166.31 | $166.31 | $218.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.36 / $166.31 / $218.29
| Professional | | $141.36 | $166.31 | $218.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.31 / $166.31 / $218.29
| Facility | | $166.31 | $166.31 | $218.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.31 / $166.31 / $218.29
| Professional | | $166.31 | $166.31 | $218.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.23 / $228.79 / $269.52
| Professional | | $87.23 | $228.79 | $269.52 |