- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.87 / $138.87 / $160.24
| Professional | | $138.87 | $138.87 | $160.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.76 / $138.76 / $209.17
| Facility | | $138.76 | $138.76 | $209.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.29 / $138.76 / $147.91
| Professional | | $101.29 | $138.76 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.76 / $138.76 / $209.17
| Facility | | $138.76 | $138.76 | $209.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.29 / $138.76 / $147.91
| Professional | | $101.29 | $138.76 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.65 / $168.58 / $328.98
| Professional | | $94.65 | $168.58 | $328.98 |