- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.71 / $291.25 / $311.20
| Professional | | $242.71 | $291.25 | $311.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.60 / $163.33 / $272.17
| Facility | | $41.60 | $163.33 | $272.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.84 / $41.60 / $48.36
| Professional | | $34.84 | $41.60 | $48.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.04 / $116.04 / $116.04
| Professional | | $116.04 | $116.04 | $116.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.71 / $291.25 / $416.49
| Facility | | $242.71 | $291.25 | $416.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.20 / $290.20 / $290.20
| Professional | | $290.20 | $290.20 | $290.20 |