- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.46 / $108.47 / $187.74
| Professional | | $108.46 | $108.47 | $187.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.18 / $141.18 / $141.18
| Professional | | $141.18 | $141.18 | $141.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $170.27 / $283.79
| Facility | | $102.33 | $170.27 | $283.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $283.79
| Professional | | $108.47 | $108.47 | $283.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $170.27 / $283.79
| Facility | | $102.33 | $170.27 | $283.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $283.79
| Professional | | $108.47 | $108.47 | $283.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $114.98 / $376.07
| Professional | | $108.47 | $114.98 | $376.07 |