- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.58 / $123.15 / $200.72
| Professional | | $106.58 | $123.15 | $200.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.35 / $132.35 / $173.71
| Facility | | $132.35 | $132.35 | $173.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.61 / $108.62 / $118.13
| Professional | | $89.61 | $108.62 | $118.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.76 / $115.76 / $115.76
| Professional | | $115.76 | $115.76 | $115.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.58 / $136.32 / $257.70
| Facility | | $106.58 | $136.32 | $257.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.73 / $148.97 / $827.90
| Professional | | $118.73 | $148.97 | $827.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.73 / $138.22 / $260.07
| Professional | | $118.73 | $138.22 | $260.07 |