- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.48 / $108.48 / $125.17
| Professional | | $108.48 | $108.48 | $125.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.38 / $182.31 / $182.31
| Facility | | $163.38 | $182.31 | $182.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.09 / $138.37 / $187.78
| Professional | | $133.09 | $138.37 | $187.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.38 / $182.31 / $182.31
| Facility | | $163.38 | $182.31 | $182.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.09 / $182.31 / $187.78
| Professional | | $133.09 | $182.31 | $187.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.94 / $167.06 / $256.99
| Professional | | $73.94 | $167.06 | $256.99 |