- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.61 / $144.61 / $226.13
| Professional | | $144.61 | $144.61 | $226.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.19 / $252.19 / $252.19
| Facility | | $252.19 | $252.19 | $252.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.19 / $252.19 / $252.19
| Professional | | $252.19 | $252.19 | $252.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.12 / $141.12 / $248.42
| Facility | | $141.12 | $141.12 | $248.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.02 / $103.02 / $224.36
| Professional | | $103.02 | $103.02 | $224.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.83 / $112.67 / $125.08
| Professional | | $101.83 | $112.67 | $125.08 |