- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.38 / $150.38 / $235.16
| Professional | | $150.38 | $150.38 | $235.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $262.27 / $262.27 / $262.27
| Facility | | $262.27 | $262.27 | $262.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.27 / $262.27 / $262.27
| Professional | | $262.27 | $262.27 | $262.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.91 / $159.91 / $375.36
| Facility | | $159.91 | $159.91 | $375.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.74 / $116.74 / $253.98
| Professional | | $116.74 | $116.74 | $253.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.40 / $127.68 / $141.75
| Professional | | $115.40 | $127.68 | $141.75 |