- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.41 / $112.41 / $175.77
| Professional | | $112.41 | $112.41 | $175.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.03 / $196.03 / $196.03
| Facility | | $196.03 | $196.03 | $196.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.03 / $196.03 / $196.03
| Professional | | $196.03 | $196.03 | $196.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.07 / $127.07 / $213.42
| Facility | | $127.07 | $127.07 | $213.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.76 / $92.76 / $179.09
| Professional | | $92.76 | $92.76 | $179.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.67 / $89.95 / $99.86
| Professional | | $84.67 | $89.95 | $99.86 |